PSYCHIATRY Flashcards

(543 cards)

1
Q

MENTAL HEALTH ACT 1983
What does the main part of the MHA allow for?

A
  • ‘Sectioning’ = compulsory admission to hospital for those that are mentally ill.
  • Drs should persuade pts to come in voluntarily if they have capacity, but not always possible (esp if they lack insight)
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2
Q

MENTAL HEALTH ACT 1983
What are the main principles of the MHA?

A
  • Respect for pts wishes + feelings (past + present)
  • Minimise restrictions on liberty
  • Public safety
  • Pts well-being + safety
  • Effectiveness of treatment
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3
Q

MENTAL HEALTH ACT 1983
What is does an individual have to show to be sectioned?

A
  • Evidence of MH disorder
  • Evidence they’re serious risk to self, safety or others
  • Evidence there is good reason to warrant attention in hospital
  • Appropriate treatment must be available for a S3
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4
Q

MENTAL HEALTH ACT 1983
What is a…
i) section 12 approved dr?
ii) approved mental health professional?

A

i) ≥ST4 Dr who has done extra training in MH to get S12 approved to section pts
ii) AMHPs are often social workers who have done extra training in MH

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5
Q

MENTAL HEALTH ACT 1983
Who can remove sections?

A
  • Consultant psychiatrist
  • MH review tribunal (MHT) if pt disagrees w/ section
  • Nearest relative can make an order to discharge pt from hospital with 72h written notice
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6
Q

MENTAL HEALTH ACT 1983
If a relative requests a section removal how can the clinician respond if they disagree?

A
  • Issue a barring report within 72h which stops discharge up to 6m from then
  • Can still apply to MHT if disagrees
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7
Q

MENTAL HEALTH ACT 1983
What is the purpose, duration, location + professionals involved for a Section 2?

A

P – admission for assessment, treatment can be given w/out consent
D – 28d, cannot be renewed, can be converted to S3
L – anywhere in community (airports, jail, A+E, etc)
Prof – 2 Drs (1x S12), 1 AMHP, or nearest relative

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8
Q

MENTAL HEALTH ACT 1983
What is the purpose, duration, location + professionals involved for a Section 3?
Who is involved if a pt is medicated without consent?

A

P – admission for treatment
D – 6m, can be renewed
L – anywhere in community
Prof – 2 Drs (1x S12), 1 AMHP, nearest relative
Second opinion appointed doctor (SOAD) – after 3m SOAD reviews if medication w/out consent is necessary

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9
Q

MENTAL HEALTH ACT 1983
What is the purpose, duration, location + professionals involved, evidence needed for a Section 4?

A

P – emergency order
D – 72h
L – anywhere in community
P – 1 S12 Dr, 1 AMHP, nearest relative
E – same as S2 but only in an urgent necessity when waiting for a second dr (for a S2) would lead to undesirable delay/outcome

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10
Q

MENTAL HEALTH ACT 1983
Where can you apply a S5?
What can the team not do?

A
  • Voluntary pt in hospital that wants to leave (NOT A+E as not admitted)
  • Coercively treat the pt
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11
Q

MENTAL HEALTH ACT 1983
What is the purpose, duration + professionals involved for a Section 5(2)?

A

P – Drs holding power, allows for S2/3 assessment
D – 72h
Prof – 1 Dr (usually in charge of their care or nominated deputy

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12
Q

MENTAL HEALTH ACT 1983
What is the purpose, duration + professionals involved for a Section 5(4)?

A

P – nurses holding power until Dr attends to assess
D – 6h
Prof – 1 registered nurse

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13
Q

MENTAL HEALTH ACT 1983
What are the 2 police sections and their differences? What is the duration and purpose of these?

A
  • S135 – needs magistrates court order to access pts home + remove them
  • S136 –person suspected of having mental disorder in a public place
    D – 24h (extend to 36h if intoxicated but should be seen sooner)
    P – taken to place of safety (local psych unit, police cell) for further assessment
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14
Q

ECT
What are the reasons why ECT can be done?
When is electroconvulsive therapy (ECT) recommended?

A
  • Rapid improvement of severe Sx after adequate trial of other Tx proven ineffective and/or condition potentially life threatening
  • Severe mania or depression, suicide risk, catatonia, Rx resistant psychosis
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15
Q

ECT
What are some contraindications to ECT?

A
  • NO absolute, all relative
  • General anaesthesia (reactions)
  • Cerebral aneurysm
  • Recent MI, arrhythmias
  • Intracerebral haemorrhage
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16
Q

ECT
What are some adverse effects of ECT?

A
  • Short-term retrograde amnesia
  • Headache
  • Confusion + clumsiness
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17
Q

DEPRESSION
What is depression?
How common is it?

A
  • Persistent low mood ± loss of pleasure in activities – unipolar depression.
  • 2–6% prevalence globally, F>M but men more likely to be substance misusers + commit suicide
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18
Q

DEPRESSION
What are 2 theories speculating the causes of depression?

A
  • Stress vulnerability = someone with high vulnerability will withstand less stress before becoming mentally unwell
  • Monoamine hypothesis = depression caused by deficiency in monoamines (serotonin, noradrenaline) hence why Tx works
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19
Q

DEPRESSION
What are the biological causes of depression?

A
  • Personal/FHx + genetics
  • Personality traits (dependent, anxious, avoidant)
  • Physical illness (hypothyroid, anaemia, childbirth)
  • Iatrogenic (beta-blockers, steroids, substance misuse)
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20
Q

DEPRESSION
What are the…

i) psychological
ii) social

causes of depression?

A

i) Disrupted relationships, child abuse, poor coping mechanisms
ii) Low socioeconomic status, poor social support, discrimination, divorce, refugee

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21
Q

DEPRESSION
What are some risk factors for depression?

A
  • Physical co-morbidities, esp. chronic + painful (MS, stroke, DM)
  • Genetics + FHx, female, older age, substance abuse
  • Traumatic events (+ve/-ve) like divorce/marriage, (un)employment, poverty, loss
  • Adverse childhood experiences like abuse, poor parent relationships
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22
Q

DEPRESSION
What are the 3 diagnostic criteria for depression?

A
  • Sx present most days ≥2 weeks + change from baselines
  • Sx not attributable to other organic or substance causes
  • Sx impair daily function + cause significant distress
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23
Q

DEPRESSION
What are the three core symptoms of depression?

A
  • Low mood
  • Anhedonia
  • Anergia
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24
Q

DEPRESSION
What are some psychological symptoms of depression?

A
  • Guilt, worthlessness, hopelessness
  • Self-harm/suicidality
  • Low self-esteem
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25
DEPRESSION What are some cognitive symptoms of depression?
- Beck's triad = negative views about oneself, the world + the future - Poor concentration + impaired memory - Avoiding social contact + performing poorly at work (social Sx too)
26
DEPRESSION What are some somatic, or biological, symptoms of depression?
- Disturbed sleep (EMW, initial insomnia, frequent waking) - Disturbed appetite + weight - Loss of libido - Diurnal mood variation (worse in morning) - Psychomotor retardation
27
DEPRESSION What are the 4 classifications of depression?
- Mild = ≥2 core + ≥2 other (minimal interference) - Mod = ≥2 core + ≥3 other (variable interference) - Severe = all core + ≥4 other (marked interference) - Psychotic = Sx of depression + psychosis
28
DEPRESSION What are some features of psychotic depression?
- Mood congruent hallucinations (auditory = derogatory or accusatory voices, olfactory = bad smells) - Nihilistic delusions - Delusions of poverty, guilt, hypochondriacal - Catatonia or marked psychomotor retardation (depressive stupor)
29
DEPRESSION What is Cotard's syndrome?
- Delusional belief that they are dead, do not exist, are rotting or have lost their blood + internal organs
30
DEPRESSION What are some... i) psychiatric ii) organic differentials for depression?
i) Dysthymia, stress-related disorders, bipolar, schizophrenia, anxiety, substance misuse/withdrawal ii) Dementia, Parkinson's, anaemia, hypoglycaemia, Addison's, Cushing's
31
DEPRESSION What are some complications of depression?
- Reduce QOL - Increased morbidity + mortality (IHD, DM) - Suicide (20x more likely than gen pop)
32
DEPRESSION What are some investigations for depression?
- FBC, ESR, B12/folate, U+Es, LFTs, TFTs, glucose, Ca2+ - ECG, MSE + risk assessment - Urine drug screen - PHQ-9 + HADS to screen for depression
33
DEPRESSION When would you consider hospital admission ± MHA in depression?
- Serious risk of suicide or harm to others - Severe depressive or psychotic symptoms - Initiation of ECT
34
DEPRESSION What is the management of mild depression?
- Watchful waiting - Low-intensity psychosocial interventions first line (computerised CBT, individual-guided CBT, structured group physical activity programme) + psychoeducation
35
DEPRESSION Should biological therapy be used in mild depression?
No unless... - Consider if PMH mod-severe depression - Mild depression for 2y or persists after interventions
36
DEPRESSION What is the management of moderate–severe depression?
- Combination of SSRI + high-intensity psychosocial interventions first line - CBT with professional, interpersonal therapy, behavioural activation therapy - Psychoeducation
37
DEPRESSION What is the CAMHS management of depression?
- Watch + wait, lifestyle - First-line = CBT ± family ± interpersonal therapy (may need intensive if no response) - 1st line antidepressant = fluoxetine - Mood + feelings questionnaire (MFQ) to follow-up monitoring in secondary care to assess progress
38
DEPRESSION What is the management for resistant depression?
- Different antidepressants (SNRI, MAOI, mirtazapine) or sometimes two - Augmentation with lithium, atypical antipsychotic or tryptophan
39
DEPRESSION What is the management of psychotic depression?
- ECT first line + v effective in severe cases followed by antidepressant - Antipsychotic initiated before antidepressant if ?primary psychotic disorder then add SSRI
40
DEPRESSION What is atypical depression? What is the management?
- Mood depressed but reactive - Hypersomnia (>10h/day) - Hyperphagia (excessive eating + weight gain) - Leaden paralysis (heaviness in limbs ≥1h/day) - Oversensitivity to perceived rejection - Phenelzine or another MAOI, if not SSRI
41
DEPRESSION What is dysthymia? What is the management?
- Chronic, low-grade or sub-threshold depressive Sx which don't meet diagnostic criteria over a long period of time - Typically >2y of mildly depressed mood + diminished enjoyment, less severe but more chronic - SSRIs + CBT first line
42
DEPRESSION What is seasonal affective disorder? What is the management?
- Episodes of depression which recur annually at same time each year (Jan-Feb) with remission in between - Light therapy + SSRI
43
SELF-HARM What is self-harm?
- Act of intentionally injuring yourself
44
SELF-HARM What does previous self-harm indicate?
Greatest predictor of future self-harm + increased suicide risk
45
SUICIDE Why is depression higher in females but suicide higher in males?
Men tend to use violent means which are irreversible
46
SELF-HARM + SUICIDE What is parasuicide? Why might this occur?
- Act that mimics suicide but does not result in death - Someone interrupts them, not enough pills, vomited some of the substances out
47
SELF-HARM + SUICIDE What are some risk factors for suicide?
SAD PERSONS – - Sex (M>F) - Age (peaks in young + old) - Depression - Previous attempt - Ethanol - Rational thinking loss (psychotic illness) - Social support lacking (unemployed, homeless) - Organised plan (avoid discovery, plan, notes, final acts) - No spouse - Sickness (physical illness) 0–4 low, 5–6 mod (?hospital), ≥7 high
48
SELF-HARM + SUICIDE What are some protective factors for suicide?
- Married men - Active religious beliefs - Social support - Good employment
49
SELF-HARM + SUICIDE What are some indicators someone may commit suicide?
- Obsessive thoughts of death, feelings of hopeless/helplessness - Active planning (buy equipment, manage affairs, leave notes
50
SELF-HARM + SUICIDE How should a suicide assessment be conducted?
- Before (?trigger) – amount of planning, notes, final acts? - During – method, attempt to avoid discovery, lethality? - After – regret? Intend to re-attempt? Evidence of hopelessness?
51
SELF-HARM + SUICIDE How should paracetamol overdose be managed?
- Acetylcysteine if staggered (>1h) or above treatment line - Rarely if present <1h then activated charcoal can be used
52
SELF-HARM + SUICIDE What is the general management for suicide?
- Plan for further suicidal thoughts + coping strategies - Reduce social isolation, regular contact with services - Manage depression (if present) - ?Inpatient stay or ECT
53
BIPOLAR DISORDER What is bipolar affective disorder? When is the peak age of onset?
- Recurrent episodes of altered mood + activity involving both upswings or (hypo)mania + downswings or depression - Early 20s
54
BIPOLAR DISORDER What are the 4 types of bipolar?
- Bipolar 1 = mania + depression in equal proportions, M>F - Bipolar 2 = more episodes of depression, mild hypomania (easy to miss), F>M - Cyclothymia = chronic mood fluctuations over ≥2y (episodes of depression + hypomania, can be subclinical) - Rapid cycling = ≥4 episodes of (hypo)mania or depression in 1 year
55
BIPOLAR DISORDER What are some potential causes of bipolar?
- Structural brain abnormalities, neurotransmitter imbalances
56
BIPOLAR DISORDER What is the diagnostic criteria for bipolar?
- ≥2 episodes of mood disturbance (1 or which MUST be [hypo]manic)
57
BIPOLAR DISORDER What is the clinical presentation of hypomania?
MANIC SYMPTOMS - elevated or irritable mood - risky behaviours - increased energy levels - functional impairment - decreased need for sleep - pressure of speech - inflated self-esteem or grandiose delusions - flight of ideas - distractibility DEPPRESSIVE SYMPTOMS - low mood - anhedonia - low energy - functional impairment - weight loss/gain - feeling of worthlessness - suicidal ideation - poor concentration
58
BIPOLAR DISORDER What is the difference between mania and hypomania?
MANIA - abnormally elevated mood or irritability - >7 days duration - severe functional impairment - psychotic symptoms e.g. delusions, hallucinations HYPOMANIA - abnormally elevated mood or irritability - >4 days duration - no significant functional impairment - no psychotic features
59
BIPOLAR DISORDER What are some... i) psychiatric ii) organic differentials for bipolar?
i) substance abuse (cocaine, amphetamines), schizophrenia, schizoaffective disorder, ADHD ii) Hyperthyroidism, steroid-induced psychosis, Cushing's
60
BIPOLAR DISORDER What investigations would you perform in suspected bipolar?
- Full Hx, MSE + physical exam to exclude organic - FBC, U+Es, LFTs, glucose, TFTs, calcium, syphilis serology, urine drug test, ?neuroimaging if SOL
61
BIPOLAR DISORDER What is the acute biological management of bipolar disorder?
MANIA - taper/stop any antidepressants - ?admission if patient is risk to self/others - 1st line = haloperidol, olanzapine, quetiapine or risperidone - 2nd line = try one of others from list above - 3rd line = lithium/sodium valproate if antipsychotics fail DEPRESSION - offer one of the following: antipsychotic (quetiapine or olanzapine), fluoxetine + olanzapine, lamotrigine - high-intensity CBT
62
BIPOLAR DISORDER What is the long-term biological management of bipolar disorder?
- Lithium first-line (antipsychotics in pregnancy) - Fluoxetine SSRI of choice if depressive episode
63
BIPOLAR DISORDER What type of referral would you do in bipolar? What is the psychological management of bipolar disorder?
- Hypomania = routine CMHT referral, - mania or severe depression = urgent - CBT for depression, bipolar support groups + psychoeducation
64
SCHIZOPHRENIA What is schizophrenia?
- Splitting or dissociation of thoughts, loss of contact with reality
65
SCHIZOPHRENIA What is the neurodevelopmental hypothesis in schizophrenia?
- Hypoxic brain injury, viral infections in-utero, TLE + cannabis smoking = risk of schizophrenia indicating brain development link - Imaging has showed enlarged ventricles (poor prognostic feature), small amounts of grey matter loss + smaller, lighter brains
66
SCHIZOPHRENIA What is the neurotransmitter hypothesis in schizophrenia?
- Excess dopamine + overactivity in mesolimbic tract = +ve Sx - Lack of dopamine + underactivity in mesocortical tracts = -ve Sx - Overactivity of dopamine, serotonin, noradrenaline + underactivity of glutamate + GABA
67
SCHIZOPHRENIA What are some risk factors?
Strongest RF = FHx, others = Black Caribbean, migrants, urban areas, cannabis use + traumatic pregnancy (emergency c-section)
68
SCHIZOPHRENIA What are the 6 different types of schizophrenia?
- Paranoid (most common) - Hebephrenic - Simple - Catatonic - Undifferentiated - Residual ('burnt out')
69
SCHIZOPHRENIA What are the features of paranoid schizophrenia?
Persecutory delusions + auditory hallucinations
70
SCHIZOPHRENIA What can cause schizophrenia?
- Thought to be combination of biopsychosocial factors - Schizophrenia susceptibility + emotional life experiences may = trigger
71
SCHIZOPHRENIA What are the first rank symptoms of schizophrenia? What is the relevance?
- Delusional perceptions - Auditory hallucinations (3 types) - Thought alienation (insertion, withdrawal + broadcasting) - Passivity phenomenon, incl. somatic - ≥1 for at least 1m is strongly suggestive Dx
72
SCHIZOPHRENIA What are the three types of auditory hallucinations that count as a first rank symptom?
- 3rd person = talking about the patient (he/she) - Running commentary = often on person's actions or thoughts - Thought echo = thoughts spoken aloud
73
SCHIZOPHRENIA What are some secondary symptoms of schizophrenia? What is the relevance?
- 2nd person auditory or hallucinations in other modalities - Other delusions (persecutory, reference) - Formal thought disorder - Lack of insight - Negative Sx (incl. catatonia) - ≥2 for at least 1m is strongly suggestive Dx
74
SCHIZOPHRENIA What is the difference between positive and negative symptoms of schizophrenia?
- +ve = presence of change in behaviour or thought, something added (all of the first rank + secondary Sx) - -ve = decline in normal functioning, something removed
75
SCHIZOPHRENIA What are the negative symptoms of schizophrenia?
Often early prodromal, 5As – - Affect blunting, flattening or incongruity - Anhedonia + amotivation - Asociality - Alogia (poverty of speech) - Apathy (Delusional mood = ominous feeling of something impending)
76
SCHIZOPHRENIA What are some... i) psychiatric ii) organic iii) substance differentials for schizophrenia?
i) Delusional disorder, transient psychosis, mania, psychotic depression ii) TLE, encephalitis, delirium, syphilis/HIV, SOL iii) Drug-induced psychosis, alcoholic hallucinosis, steroid-induced
77
SCHIZOPHRENIA What are the investigations for first-episode psychosis?
- Full Hx, MSE + risk assessment - FBC, CRP/ESR, U+Es, LFTs, TFTs, fasting glucose, Ca2+, phosphate, B12 + folate - Urine + serum drugs screen - ?Serological syphilis + HIV - CT/MRI head if ?SOL
78
SCHIZOPHRENIA What is the management of schizophrenia?
1ST LINE - atypical antipsychotic - psychological interventions e.g. CBT, art therapy + family interventions 2ND LINE - alternative antipsychotic 3RD LINE - clozapine
79
SCHIZOPHRENIA What would warrant hospital admission ± MHA in schizophrenia?
- High risk of suicide or homicide - Severe psychotic, depressive or catatonic Sx - Failure of OP treatment or non-compliance
80
SCHIZOPHRENIA What is the biological management of schizophrenia?
- Anti-psychotic (tailor SE profile to patient) - Aim for minimal effective dose, use depot if non-compliant to prevent relapse
81
SCHIZOPHRENIA What is treatment resistant schizophrenia? What is the management?
- ≥2 antipsychotics (1 atypical) trialled for ≥6w but ineffective - Clozapine - ECT is last line if resistant to therapy or catatonic
82
SCHIZOPHRENIA What is the psychological management for schizophrenia?
- All patients offered CBT - Family therapy + psychoeducation to reduce or notice relapses
83
SCHIZOPHRENIA What is the social management of schizophrenia?
- Social work + housing involvement may be needed - Drop-in community centres + support groups - Substance misuse service if needed - Depot non-attendance at GP/CPN appt may act as early warning system
84
SCHIZOPHRENIA After a Mental Health Act detention, what approach should be taken to their care? What does it involve?
- Care programme approach - Assess health + social needs, create care plan, appoint key worker as point of contact + review treatment
85
PARAPHRENIA What is paraphrenia? How does it compare to schizophrenia?
- Late-onset schizophrenia >45y - Less emotional blunting + personality decline, F>M
86
PARAPHRENIA Why is it often undiagnosed? What are some risk factors?
- Older patients tend to be socially isolated - Social isolation, poor eyesight + hearing, reclusive + suspicious pre-morbid personality
87
PARAPHRENIA What is the clinical presentation of paraphrenia? How is it managed?
- Delusions, hallucinations + paranoia usually about neighbours - Partition delusions where they believe people + objects can go through walls - Less -ve Sx + formal thought disorder - Low dose antipsychotics
88
TRANSIENT PSYCHOSIS What is transient psychosis? What may cause it? What is it associated with?
- Brief psychotic episodes that last less than time required to diagnose schizophrenia (<1m) - Usually resolves within that time - Acute stressor (loss, marriage, unemployment) - Paranoid, borderline + histrionic personality disorders
89
DELUSIONAL DISORDER What is a delusional disorder?
- Pt experiences strong delusional beliefs (often non-bizarre) + perceptions but with the absence of prominent hallucinations, thought or mood disorder or significant flattened affect - ICD 10 ≥3m (if less it's persistent delusional disorder)
90
DELUSIONAL DISORDER What is erotomania or De Clerambault's syndrome?
- Delusion in which patient (usually single woman) believes another person (typically higher social status) is in love with them
91
DELUSIONAL DISORDER What is Othello syndrome?
- Delusional jealousy - Patients (typically men) possess fixed belief that their partner has been unfaithful + often try to collect evidence
92
DELUSIONAL DISORDER How else might delusional disorder present?
- Delusions about illness, cancer or skin infestation - Grandiose delusions - Persecutory delusions
93
DELUSIONAL DISORDER What is the management of delusional disorder?
- Antipsychotics, ?SSRIs - Individual therapy = establish therapeutic alliance, maybe CBT
94
SCHIZOAFFECTIVE What is schizoaffective disorder?
- Features of both affective disorder + schizophrenia present in equal proportion
95
SCHIZOAFFECTIVE What is the prognosis of schizoaffective disorder? What is the management of it?
- Better than schizophrenia but worse than primary mood disorders - Antipsychotics, mood stabilisers of antidepressants (depends on affective disorder)
96
GAD What is Generalised Anxiety Disorder (GAD)? What can it be comorbid with?
- Syndrome of excessive, persistent worry + apprehensive feelings about everyday events that the patient recognises as excessive + inappropriate - Other anxiety disorders, depression, substance abuse, IBS
97
GAD What are 3 cardinal features of GAD?
- Symptoms of muscle + psychic tension - Causes significant distress + functional impairment - No particular stimulus
98
GAD What is the epidemiology of GAD?
- Highest prevalence 45–69y, F>M - Early onset = childhood fears + marital or sexual disturbance - Late onset = stressful event, single, unemployment
99
GAD What model can be used to explain the causes of GAD?
Triple vulnerability – - Generalised biological - Generalised psychological (diminished sense of control) - Specific psychological (stressful events)
100
GAD What are some organic differentials for GAD?
- Endo = hyperthyroidism, pheochromocytoma, hypoglycaemia - CVS = arrhythmias, cardiac failure, anti-hypertensives, MI - Resp = asthma (excessive salbutamol), COPD, PE
101
GAD What are some risk factors for GAD?
- Alcohol, BDZs or stimulants (particularly withdrawal) - Co-existing depression, FHx, female - Child abuse/neglect or excessively pushy parents - Life stresses (finance, divorce) - Physical health problems
102
GAD What is the ICD criteria of GAD? What are the groups of symptoms present in GAD?
- Difficulty controlling worry, present for more days than not for ≥6m - ≥4 symptoms with ≥1 from autonomic arousal section - Autonomic arousal, physical, mental, general, tension, other
103
GAD What symptoms in GAD come under the following categories... i) autonomic arousal? ii) physical? iii) mental? iv) general? v) tension? vi) other?
i) Palpitations, tachycardia, sweating, tremor ii) Breathing issues, choking, CP, nausea, abdo distress iii) Dizzy, derealisation + depersonalisation, fear of losing control, impending death iv) Numbness + tingling, hot flushes + chills, sleep issues (initial insomnia, fatigue on waking) v) Muscle aches + pains, restless, lump in throat vi) Exaggerated responses to minor surprises/startled
104
GAD What are the investigations for GAD?
- History, MSE + risk assessment - GAD-7 + Hospital Anxiety + Depression Scale (HADS) questionnaire - Exclude organic (FBC, U+Es, LFTs, TFTs, fasting glucose, PTH)
105
GAD What is the stepwise management for GAD?
STEP 1 - education about GAD - active monitoring STEP 2 - self-help, individual guided self-help STEP 3 - CBT or SSRI (sertraline) STEP 4 - refer for specialist treatment
106
GAD What is the role of CBT in GAD?
- Cognitive = educate about bodily response to anxiety - Behavioural = use of relaxation to overcome
107
GAD What is the biological management used in GAD?
- Sertraline first line, if ineffective offer alternative SSRI or SNRI - If SSRI/SNRI not tolerated then pregabalin - Beta-blockers like propranolol for physical Sx sometimes
108
GAD What is the CAMHS management of GAD?
- Watch + wait - Self-help (meditation, mindfulness), diet + exercise - CBT, counselling + SSRI like sertraline may be considered if more severe (specialists)
109
PANIC DISORDER What is panic disorder?
- Recurrent panic attacks that are unpredictable + unrestricted in terms of situation, ≥4/week for ≥4w - Usually persistent worry about having another attack - Chronic relapsing condition > distress + social dysfunction
110
PANIC DISORDER What is a panic attack?
- Period of intense fear characterised by range of physical Sx that develop rapidly, peak intensity at 10m, generally no longer than 20–30m
111
PANIC DISORDER What is the epidemiology of panic disorder?
- Females 2–3x more likely - Bimodal distribution
112
PANIC DISORDER What is panic disorder associated with? What are some risk factors?
- Meds like SSRIs, BDZs, zopiclone withdrawal - Widowed, divorced or separated, living in city, limited education, physical or sexual abuse, FHx
113
PANIC DISORDER What are the 3 key elements of panic disorder?
- Sudden onset panic attack with ≥4 characterised Sx - Not necessarily associated with a specific stimulus - Pt preoccupied with suffering death or severe life-threatening illness
114
PANIC DISORDER What are the features of panic attacks?
Same as GAD but in discrete attacks – - Palpitations, tachycardia, sweating, tremor - Breathing issues, choking, CP, nausea, abdo distress - Dizzy, derealisation + depersonalisation, fear of losing control, impending death - Numbness + tingling, hot flushes + chills, muscle aches + pains
115
PANIC DISORDER What is the stepwise management of panic disorder?
- Recognition + diagnosis with treatment in primary care - CBT or drug therapy (SSRIs 1st line, if C/I or no response after 12w then imipramine or clomipramine) - Psychodynamic psychotherapy + specialist MH services if severe
116
PANIC DISORDER What is the social management of panic disorder?
- Healthy eating, exercise, avoid caffeine. - Meditation, mindfulness, self-help groups
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SIMPLE PHOBIAS What is a simple or specific phobia?
- Recurring excessive + unreasonable anxiety attacks, in the (anticipated) presence of a specific feared object or situation, leading to avoidance if possible
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SIMPLE PHOBIAS What might people be phobic of? Give some examples.
- Animals, blood, injection or injury, situational, natural environment - Emetophobia, claustrophobia, arachnophobia, iatrophobia
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SIMPLE PHOBIAS What is the epidemiology of simple phobias?
- F>M - Mean age is 15 (animal phobias can be as young as 7)
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SIMPLE PHOBIAS What are some potential causes of phobias?
- Psychoanalytical = phobia is symbolic representation of repressed unconscious conflict - Learning theory = conditioned fear response to traumatic situation with learned avoidance
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SIMPLE PHOBIAS What is the clinical presentation of simple phobias?
Same features as GAD but to a specific stimulus – - Palpitations, tachycardia, sweating, tremor - Breathing issues, choking, CP, nausea, abdo distress - Dizzy, derealisation + depersonalisation, fear of losing control, impending death - Numbness + tingling, hot flushes + chills, muscle aches + pains
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SIMPLE PHOBIAS What is the management of simple phobias?
- Exposure + response prevention (ERP) - CBT (education + anxiety management, coping strategies) - BDZs in severe cases to reduce avoidance
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SIMPLE PHOBIAS What are the two methods of ERP? Which is preferred?
- Desensitisation with relaxation + graded exposure - Flooding where exposed to most frightening situation instantly - Desensitisation as flooding can be highly traumatic
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AGORAPHOBIA What is agoraphobia?
- Anxiety + panic symptoms associated with places or situations where escape may be difficult or embarrassing leading to avoidance. - ≥2 from: crowds, public places, travelling alone or away from home.
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AGORAPHOBIA What may be seen in patients with agoraphobia? What is the epidemiology?
- Predisposition towards overly interpreting situations as dangerous - F>M, 15–35y, may have co-morbid panic disorder
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AGORAPHOBIA What is the clinical presentation of agoraphobia?
Same as GAD but to the specific situations – - Palpitations, tachycardia, sweating, tremor - Breathing issues, choking, CP, nausea, abdo distress - Dizzy, derealisation + depersonalisation, fear of losing control, impending death - Numbness + tingling, hot flushes + chills, sleep issues (initial insomnia, fatigue on waking)
127
AGORAPHOBIA What is the biological management of agoraphobia?
- SSRIs as for panic disorder - BDZs for short-term use only (clonazepam)
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AGORAPHOBIA What is the psychological management of agoraphobia?
- CBT (teach about bodily responses related to anxiety and exposure + desensitisation techniques, relaxation training)
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SOCIAL PHOBIA What is social phobia?
- Sx of incapacitating anxiety that are restricted to particular social situations, leading to a desire for escape or avoidance (may reinforce belief of social inadequacy)
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SOCIAL PHOBIA What is the epidemiology of social phobia?
- Bimodal distribution with peaks at 5y + 11–15y, may present in 30s
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SOCIAL PHOBIA What is the clinical presentation of social phobia?
≥2 Somatic Sx in response to the situation – - Blushing, trembling, dry mouth, sweating - Excessive fear of humiliation, embarrassment, micturition or others noticing how anxious they are. - Characteristically self-critical + perfectionist
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SOCIAL PHOBIA What is the impact of social phobia?
- Avoiding situations may lead to relationship issues, education + vocational problems (difficulty interacting with others, presentations)
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SOCIAL PHOBIA What is the biological management of social phobia?
- SSRIs (sertraline) > SNRIs > MAOIs - Beta-blockers like propranolol - Clonazepam may be useful short-term
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SOCIAL PHOBIA What is the psychological management of social phobia?
- Either individual or group CBT first-line with SSRI (relaxation training, social skills, graded exposure) - Psychodynamic psychotherapy
135
OCD What is obsessive compulsive disorder (OCD)?
- Condition characterised by obsessions + compulsions which must cause distress or interfere with their social or individual functioning (usually by wasting time)
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OCD What are some examples of obsessions and compulsions?
- Obsessions = being followed, everything being dirty or contaminated - Compulsions = checking, washing, doubting, bodily fears, counting, symmetry, aggressive thoughts
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OCD What are the two types of compulsions? What is the natural cycle in OCD?
- Overt = can be observed (checking the door) - Covert = can't be observed (repeating a phrase in their mind) - Obsession > anxiety > compulsion > relief
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OCD What is the epidemiology of OCD?
- Adolescents or early adulthood (20y mean age), M=F
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OCD What are some risk factors for OCD?
- Genetics = FHx of OCD or tic disorder - Abuse, neglect, teasing + bullying - Parental overprotection - Paediatric neuropsychiatric disorders associated with streptococci (PANDAS)
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OCD What are the key features of OCD?
- Obsessions ± compulsions present most days >2w - Acknowledged as excessive + unreasonable + originate from inside patient's mind (not influenced by outside) - Repetitive or unpleasant + pt tries to resist them unsuccessfully - Time consuming, interferes with ADLs, distress to pt - Avoidance of stimuli that trigger Sx
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OCD What is the biological management of OCD?
- 1st line SSRIs = sertraline - 2nd line = clomipramine (TCA) with specific anti-obsessional action - ?Psychosurgery (stereotactic cingulotomy if intractable > 2 antidepressants, 3 combination Tx, ECT + behavioural therapy
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OCD What is the psychological management of OCD?
- CBT but behavioural approach - ERP (stop carrying out compulsion in response to stimulus) - Psychotherapy (incl. family, groups)
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OCD What is the OCD management for CAMHS?
- Mild can be managed with psychoeducation or self-help - Referral to CAMHS, CBT + initiation of SSRI with CAMHS specialist guidance
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PTSD What is post-traumatic stress disorder (PTSD)? What counts as a traumatic event?
- Severe psychological disturbance following a traumatic event (within 6m usually). - Catastrophic event where there is threat to security or physical integrity (life-threatening) such as war, surviving tsunami, sexual assault, not everyday trauma (divorce)
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PTSD What are some risk factors for PTSD?
- Low education or social class - F>M - Previous PTSD/psych issues - First responders (ambulance, police, fire) - Military (dependent on duration of combat exposure, lower rank, low morale)
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PTSD What are the 4 core symptoms of PTSD? How long do they need to be present for to diagnose?
HEAR (≥1m) – - Hyperarousal - Emotional numbing - Avoidance + rumination - Re-experiencing (involuntary)
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PTSD In terms of PTSD, what are signs of... i) hyperarousal? ii) emotional numbing?
i) Hypervigilance for threat, exaggerated startle response, irritability, difficulty concentrating or sleeping (falling + staying asleep) ii) Difficulty experiencing emotions, restricted range of affect, detachment from others
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PTSD In terms of PTSD, what are signs of... i) avoidance + rumination? ii) re-experiencing?
i) Avoiding people, situations, thoughts or circumstances resembling or associated to event ii) Flashbacks, nightmares, vivid memories, distressing images or other sensory impressions from event which intrude during waking day, reminders of event = distress
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PTSD What is the mainstay of management in PTSD?
Psychological therapy – - Trauma-focused CBT - Eye movement desensitisation and reprocessing (EMDR)
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PTSD What is trauma-focused CBT?
- Education about nature of PTSD, self-monitoring of Sx, anxiety management, breathing techniques + exposure in supportive setting
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PTSD What is EMDR?
- Voluntary multi-saccadic eye movements to reduce anxiety associated with disturbing thoughts + help process emotions
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PTSD What is the medical management of PTSD?
- Venlafaxine or SSRI like sertraline - Risperidone for severe cases where resistant to treatment or psychotic
153
ANOREXIA NERVOSA What are the 2 types of anorexia nervosa?
- Restrictive = limit food intake - Binge/purge = binge eat + purge straight away (different from bulimia due to BMI)
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ANOREXIA NERVOSA How is anorexia classified based on BMI?
- Anorexia = <17.5kg/m^2 - Medium risk = 13–15 - High risk = <13
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ANOREXIA NERVOSA What is the epidemiology of anorexia?
- F>M - Onset is early to mid adolescence
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ANOREXIA NERVOSA What premorbid experiences may lead to anorexia development?
- Dieting behaviour in family/personal experience, over-protective family - Criticism about weight, personal Hx of obesity, adverse events (abuse) - Perfectionism, low self-esteem, disturbed body image, obsessional traits
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ANOREXIA NERVOSA What is the diagnostic criteria for anorexia?
FEED ≥3m with absence of binge eating – - Fear of fatness - Endocrine disturbance - Extreme weight loss - Deliberate weight loss
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ANOREXIA NERVOSA What are the clinical features of anorexia?
SYMPTOMS - calorie restriction - prevention of weight gain (purging or laxatives) - fear of gaining weight - body image disturbance - fatigue and poor concentration - amenorrhoea SIGNS - low BMI - dry skin and hair loss - hypothermia - bradycardia - postural hypotension - enlarged salivary glands
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ANOREXIA NERVOSA What are some complications of anorexia?
- Osteoporosis, thyroid issues, cardiac atrophy - Electrolyte disturbances (hypokalaemia > arrhythmias) - Decrease in WBC > increased infections - Death due to health complications or suicide
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ANOREXIA NERVOSA What screening tool can be used in anorexia?
SCOFF – - Do you ever make yourself SICK as too full? - Do you ever feel you've lost CONTROL over eating? - Have you recently lost more than ONE stone in 3m? - Do you believe you're FAT when others say you're thin? - Does FOOD dominate your life?
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ANOREXIA NERVOSA What are some investigations for anorexia?
- Sit up squat stand (SUSS) test /3 - BP (low), temp (low) - ECG (brady, T-wave changes, QTc prolongation) - FBC (anaemia, dehydrated), LFTs, urinalysis, serum proteins - U+Es, Ca2+, Mg2+, phosphate > vomiting, laxatives, diuretics, water loading - DEXA scan after 1y of underweight (osteopenia)
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ANOREXIA NERVOSA In anorexia, most things are low apart from what?
Gs + Cs – - GH, Glucose, salivary Glands - Cortisol, Cholesterol, Carotinaemia
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ANOREXIA NERVOSA What risk assessment tool can be used for assessing if a patient with anorexia needs inpatient psychiatric admission?
Management of Really Sick Patients with Anorexia Nervosa (MARSIPAN)
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ANOREXIA NERVOSA What are the MARSIPAN indicators of admission?
- BMI <13, severe malnutrition or dehydration - HR <40, ECG changes - BP <90 systolic, <70 diastolic esp with postural drop - Temp <35 - Severe electrolyte disturbances (K+, Na+, Mg2+, phosphate = low) - SUSS test of 0 or 1 - Significant suicide or serious self-harm risk
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ANOREXIA NERVOSA How should the physical complications of anorexia be managed?
- Monitor U+Es + ECGs - Oral supplements for electrolytes, thiamine - Multivitamins + mineral supplements, calcium + vitamin D - Safely + slowly re-feed pt + avoid refeeding syndrome
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ANOREXIA NERVOSA What are the biological treatments for anorexia nervosa?
- Fluoxetine, chlorpromazine + TCAs may be used for weight gain
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ANOREXIA NERVOSA What are the psychological therapies for anorexia?
- Individual therapy (eating disorder focussed CBT, CBT-ED) - Maudsley anorexia nervosa treatment for adults (MANTRA) - Specialist supportive clinical management (SSCM)
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ANOREXIA NERVOSA What is the social management for anorexia?
- Avoid over exercise - Food diary/dietary advice - Self-help groups
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ANOREXIA NERVOSA What is the CAMHS treatment for anorexia?
- Family therapy 1st line, pt + carer education, self-help resources - Adolescent-focussed psychotherapy, individual CBT-ED - May require SSRIs
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ANOREXIA NERVOSA What is refeeding syndrome? What are some risk factors?
- Metabolic disturbances due to reintroduction of nutrition to a starving patient who is fed too much, too quickly - Low BMI, poor nutritional intake (>5d), Hx of high alcohol intake, chemo, unintentional weight loss
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ANOREXIA NERVOSA What is the pathophysiology of refeeding syndrome?
- Reduced carb consumption leads to reduced insulin secretion so the body switches from carb > fat + protein metabolism - Electrolyte stores depleted as needed to convert glucose>energy - Reintroducing food causes abrupt shift from fat>carb metabolism + insulin secretion surges, driving electrolytes from serum>cells to help convert glucose>energy causing further serum concentration decrease
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ANOREXIA NERVOSA What is the clinical presentation of refeeding syndrome?
- Fatigue, weakness, confusion, dyspnoea (risk of fluid overload) - Abdo pain, vomiting, constipation, infections
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ANOREXIA NERVOSA What are the biochemical features of refeeding syndrome?
- Hypophosphataemia main disturbance due to role of converting glucose>energy - Hypokalaemia, hypomagnesaemia + thiamine deficiency too - Abnormal fluid balance
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ANOREXIA NERVOSA What should be monitored before + during refeeding?
- U+Es (Na+, K+), phosphate, magnesium, glucose, ECG, fluid balance
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ANOREXIA NERVOSA What is the management of refeeding syndrome?
- Start up to 10cal/kg/day + increase to full needs SLOWLY over 4–7d - Start PO thiamine, B vitamins + supplements before + during feeding - K+, phosphate + magnesium replacement
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BULIMIA NERVOSA What is bulimia nervosa?
- Characterised by recurrent episodes of binge eating + compensatory behaviours (purges)
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BULIMIA NERVOSA What is a binge?
- Episodes of overeating a large amount of food in a discrete period of time where an individual feels that they cannot control their eating
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BULIMIA NERVOSA What are purges?
- Compensatory behaviours to prevent weight gain like induced vomiting, laxative misuse, diuretics, appetite suppressants, enemas, fasting or excessive exercise
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BULIMIA NERVOSA What is the epidemiology + aetiology of bulimia?
- F>M, common in adolescent, very common premorbid experiences to anorexia (dieting behaviour, weight criticisms, perfectionism)
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BULIMIA NERVOSA What is the diagnostic criteria for bulimia?
BPFO ≥2 a week for ≥3m – - Behaviours to prevent weight gain - Preoccupation with eating (compulsion to eat but regret after) - Fear of fatness - Overeating ≥2/week
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BULIMIA NERVOSA What are some physical symptoms of bulimia?
SYMPTOMS - recurrent episodes of binge eating - feelings of loss of control during binges - compensatory behaviours (induced vomiting, laxative use or diuretic abuse, excessive exercise) - preoccupation with body weight and shape - thinking about food a lot SIGNS - erosion of tooth enamel - enlarged salivary glands - Russell's sign (calluses/scars on knuckles from induced vomiting) - weight fluctuations - warning signs (eating very rapidly, goes to bathroom very soon after eating)
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BULIMIA NERVOSA What are some complications of bulimia?
- Cardiomegaly (ipecac toxicity = plant taken PO + can cause vomiting) - Arrhythmias, cardiac failure - Mallory-Weiss tears from vomiting
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BULIMIA NERVOSA What are some investigations for bulimia?
- SCOFF - BP (low), temp, SUSS test - ECG (arrhythmias from hypokalaemia) - FBC (anaemia), LFTs, urinalysis, serum proteins - Monitor U+Es, calcium, magnesium, phosphate in vomiting, laxative abuse, diuretics or waterloading (for deceitful weighing)
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BULIMIA NERVOSA What metabolic abnormalities may be present?
- Hypochloraemic hypokalaemic metabolic alkalosis due to vomiting - Hypokalaemia > muscle weakness + arrhythmias
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BULIMIA NERVOSA When should bulimia be managed as inpatient?
- Suicidality, physical problems, extreme refractory cases - Pregnancy (risk of spontaneous abortion)
186
BULIMIA NERVOSA What is the management of bulimia?
- Guided self-help first line with psychoeducation + support group - CBT-ED - Bulimia focussed family therapy in CAMHS - Limited evidence for high-dose fluoxetine
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BINGE EATING DISORDER What is binge eating disorder?
- Episodes where person excessively overeats, often as expression of underlying psychological distress - Not restrictive so tends to be overweight
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BINGE EATING DISORDER How does binge eating disorder present?
- Planned bine with binge foods - Eating very quickly + becoming uncomfortably full - Eating in "dazed" state - Unrelated to if hungry
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BINGE EATING DISORDER What is the management of binge eating disorder?
- Self-help, CBT-ED, may benefit from SSRIs
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PERSONALITY DISORDERS What are personality disorders?
- Deeply engrained + enduring patterns of behaviour that are abnormal in a particular culture
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PERSONALITY DISORDERS What is the epidemiology of personality disorders?
- Younger adults - Antisocial PD most prevalent amongst prisoners - Dx not made in <18 as personality still developing
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PERSONALITY DISORDERS What are some risk factors for personality disorders?
- FHx of PD or other mental illness - Abusive, unstable or chaotic life - Adverse events - Dx of childhood conduct disorder (antisocial PD)
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PERSONALITY DISORDERS What are cluster A personality disorders?
- Characterised by odd, eccentric thinking or behaviour - MAD
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PERSONALITY DISORDERS What is paranoid personality disorder?
- pattern of suspiciousness about others - tendency to perceive attacks on their character + questions loyalty of friends - hypersensitivity + unforgiving when insulted - preoccupation with conspiracy beliefs + hidden meaning - reluctance to confide in others - are less resistant to change their beliefs when challenged compared to a patient with delusions
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PERSONALITY DISORDERS In terms of paranoid personality disorder... i) think the world is? ii) think people are? iii) acts as if? iv) common behaviour? v) least likely to be? vi) emotional hotspot?
i) Conspiracy ii) Devious, trying to cause harm iii) Always on guard + suspicious of others, emotionally cold/distant iv) Watchfulness v) Trusting (fear others will use information against you) vi) Being discriminated against
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PERSONALITY DISORDERS What is schizoid personality disorder?
- emotional coldness - lack of desire for companionship - preference for solitary activities - few friends or confidants - lack of interest in sexual interactions
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PERSONALITY DISORDERS In terms of schizoid personality disorder... i) think the world is? ii) think people are? iii) thinks they are? iv) common behaviour? v) least likely to be? vi) emotional hotspot? vii) other?
i) Uncaring ii) Pointless, replaceable iii) Only person they can depend on iv) Withdrawal, prefer to be alone v) Emotionally available + close vi) Being over-cared for or smothered by others vii) Inability to take pleasure from activities, little interest in sex
198
PERSONALITY DISORDERS What is schizotypal personality disorder?
- odd, eccentric behaviour or 'magical thinking' - inappropriate behaviour - ideas of reference (applying meaning to coincidences or innocuous events) - peculiar speech, mannerisms or dress code - are not psychotic
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PERSONALITY DISORDERS What are some features of schizotypal personality disorder?
- Ideas of reference (not delusions as insight) - Excessive social anxiety with lack of close friends + social withdrawal - "Magical thinking" believing you can influence people/events with thoughts - Unusual perceptions (illusions, overvalued ideas) - Odd/eccentric behaviour, beliefs, speech or appearance - Inappropriate affect with paranoid or suspicious ideas
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PERSONALITY DISORDERS What are some differentials of schizotypal personality disorder?
- Autism - Asperger's - Schizophrenia (50% may develop it)
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PERSONALITY DISORDERS What are cluster B personality disorders?
- Characterised by dramatic, overly emotional or unpredictable thinking or behaviour (BAD)
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PERSONALITY DISORDERS What is dissocial/antisocial personality disorder?
- Childhood conduct disorder before 15 + pattern of irresponsible + antisocial behaviour after age 15
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PERSONALITY DISORDERS What is a psychopath? What is a sociopath?
- When they get in trouble with the law - Same traits but without law involvement
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PERSONALITY DISORDERS In terms of antisocial personality disorder... i) think the world is? ii) think people are? iii) thinks they are? iv) common behaviour? v) least likely to be? vi) emotional hotspot? vii) other?
i) Predatory ii) Weak iii) Autonomous + alone iv) Aggressive/violent v) Gentle + sensitive, conform to social norms vi) Perceiving exploitation vii) Disregard for others' needs, feelings, safety, impulsive + lacks remorse
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PERSONALITY DISORDERS What is borderline/emotionally unstable personality disorder? What is a big risk factor?
- intense and unstable interpersonal relationships - unstable affect regulation (variable, intense moods) - repeated self-injury and suicidality - Often Hx of childhood sexual abuse
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PERSONALITY DISORDERS what are the clinical features of EUPD?
UNSTABLE SELF IMAGE - low self esteem - recurrent suicidal/self-harming behaviour IMPULSIVITY - self-sabotaging or risk-taking behaviour - difficulty controlling temper POOR INTERPERSONAL RELATIONSHIPS - short romantic relationships - feelings of abandonment - idealisation + devaluation of others PARANOIA - quasi-psychotic thoughts in response to stress (transient psychosis that is not prolonged and does not require medication)
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PERSONALITY DISORDERS In terms of EUPD... i) think the world is? ii) think people are? iii) common behaviour? iv) least likely to be? v) emotional hotspot? vi) other?
i) Contradictory ii) Untrustworthy iii) Self-harm/suicide (impulsive + unpredictable) iv) Able to show self-compassion v) Abandonment (extreme reactions) vi) Paranoid when stressed, labile mood, unstable + intense relationships
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PERSONALITY DISORDERS In terms of EUPD, what is the difference between... i) impulsive type? ii) borderline type?
i) Difficulties with impulsive + risky behaviours (unsafe sex, gambling) + anger ii) Difficulties with relationships, self-harm + feelings of emptiness
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PERSONALITY DISORDERS What is histrionic personality disorder?
- exaggerated dramatic behaviour designed to attract attention - attention seeking - flirtatious, seductive, charming and lively - manipulative and impulsive - uncomfortable when they are not the centre of attention - may embarrass friends/family with public displays of emotion - consider their relationships to be closer than they actually are
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PERSONALITY DISORDERS In terms of histrionic personality disorder... i) think the world is? ii) think people are? iii) common behaviour? iv) least likely to be? v) emotional hotspot? vi) think they are? vii) think relationships with others are?
i) Their audience (crave attention) ii) In competition for attention iii) Exhibitionism (provocative for attention) iv) Able to listen to others v) Actively or passively side-lined vi) Vivacious, easily influenced by others, excessive concern with physical appearance vii) Closer than what they really are
211
PERSONALITY DISORDERS What is narcissistic personality disorder?
- grandiose sense of self-importance (e.g. exaggeration of achievements) - sense of entitlement + expectation of favourable treatment - arrogant, haughty behaviour - believes they are special + can only be understood by other special people - lacks empathy + often exhibits envy
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PERSONALITY DISORDERS In terms of narcisssitic personality disorder... i) think the world is? ii) think people are? iii) thinks they are? iv) common behaviour? v) least likely to be? vi) emotional hotspot? vii) other?
i) Competition ii) Inferior iii) Special + more important than others iv) Competitiveness v) Humble vi) Loss of social rank/status or being embarrassed vii) Failure to recognise other's needs or feelings, arrogance, envy (both ways)
213
PERSONALITY DISORDERS What are cluster C personality disorders?
- Characterised by anxious, fearful thinking or behaviour (SAD)
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PERSONALITY DISORDERS What is anxious/avoidant personality disorder?
- avoidance of feared stimuli - major fears include fear of criticism and rejection - views self as inept and inferior - extreme social anxiety - strong desire for intimacy - strongly linked to childhood issues (neglect + abuse)
215
PERSONALITY DISORDERS In terms of anxious/avoidant personality disorder... i) think the world is? ii) think people are? iii) thinks they are? iv) common behaviour? v) least likely to be? vi) emotional hotspot? vii) other?
i) Evaluative ii) Judgemental iii) Inept iv) Inhibition (social, avoids this) v) Assertive vi) Exposed, ridicule, criticism or rejection vii) Feeling inadequate or inferior, extreme shyness, fear of disapproval
216
PERSONALITY DISORDERS What is dependent personality disorder?
- difficulty in decision making without excessive reassurance - lack of initiative or extreme passivity - will make effort to encourage others to make decisions regarding their own life - often seen in those with overprotective or authoritarian parents
217
PERSONALITY DISORDERS In terms of dependent personality disorder... i) think the world is? ii) think people are? iii) they are? iv) common behaviour? v) least likely to be? vi) emotional hotspot? vii) other?
i) Overwhelming ii) Stronger + more competent than themselves iii) Needy iv) Clinging v) Self-sufficient vi) Making a decision, abandonment vii) Requires excessive advice/reassurance, tolerant of abusive treatment, relationship hops, difficult disagreeing with others
218
PERSONALITY DISORDERS What is anankastic/obsessive-compulsive personality disorder? What may it be seen in?
- Pervasive pattern of perfectionism + inflexibility lacking insight - Hx of family pressure + wanting approval
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PERSONALITY DISORDERS In terms of anankastic/OC personality disorder... i) think the world is? ii) think people are? iii) think they are? iv) common behaviour? v) least likely to be? vi) emotional hotspot? vii) other?
i) Sloppy ii) Irresponsible iii) Responsible iv) Controlling v) Flexible vi) Making a mistake vii) Preoccupied with order, extreme perfectionism, neglect friends due to excessive project commitment, rigid + stubborn
220
PERSONALITY DISORDERS What are some investigations for personality disorders?
- Assessed (Hx + MSE) more than once - Minnesota Multiphasic Personality Inventory (MMPI) - Eysenck Personality Inventory + Personality Diagnostic Questionnaire
221
PERSONALITY DISORDERS What is the biological management of personality disorders?
- Only use to treat comorbid conditions or if Sx distressing (e.g. antipsychotics in group A to reduce suspiciousness)
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PERSONALITY DISORDERS What are the psychological therapies for personality disorders?
- Dialectical behavioural therapy for EUPD - CBT (change unhelpful ways of thinking) - Cognitive analytical therapy (recognise + change unhelpful patterns in relationships + behaviours) - Psychodynamic therapy (looks at how past experiences affect present behaviour)
223
DELIRIUM TREMENS What is delirium tremens?
- Acute, toxic confusional state secondary to alcohol withdrawal (48–72h after)
224
DELIRIUM TREMENS How does delirium tremens present?
- Clouding of consciousness, disorientation + amnesia of recent events - Autonomic = diaphoresis, fever, tachycardia (risk of CV collapse) - Psychomotor agitation, delusions + coarse tremor - Visual, auditory + tactile hallucinations
225
DELIRIUM TREMENS Describe the hallucinations in delirium tremens
- Characteristically of small people or animals (Lilliputian hallucinations) - May feel 'ants crawling'
226
DELIRIUM TREMENS What is the management of delirium tremens?
- ABCDE approach as emergency - IV thiamine (pabrinex), supportive fluids - PO lorazepam first line to prevent fitting (IV or haloperidol if refused)
227
WERNICKE'S What is Wernicke's encephalopathy?
- Atrophy of mammillary bodies due to thiamine deficiency, often alcohol abuse
228
WERNICKE'S How does Wernicke's present?
Triad – - Ataxia - Confusion - Ophthalmoplegia + nystagmus
229
WERNICKE'S What is the management of Wernicke's?
- ABCDE approach as emergency - IV pabrinex immediately - Treat high risk patients (alcoholics) with prophylactic vitamins
230
KORSAKOFF'S What is Korsakoff's psychosis?
- Thiamine deficiency causes damage + haemorrhage to the mammillary bodies of the hypothalamus + medial thalamus - Complication of untreated Wernicke's
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KORSAKOFF'S What are some causes of Korsakoff's?
- Heavy alcohol drinkers - Head injury, post-anaesthesia - Basal or temporal lobe encephalitis - CO poisoning - Other causes of thiamine deficiency (anorexia, starvation, hyperemesis)
232
KORSAKOFF'S What is the clinical presentation of Korsakoff's?
- Profound short-term memory loss with inability to lay down new memories (antero + retrograde amnesia) - Confabulation
233
KORSAKOFF'S What is the management of Korsakoff's?
- ABCDE approach as emergency - PO thiamine replacement + multivitamin supplements (for up to 2y) - OT assessment + cognitive rehab
234
LITHIUM TOXICITY What is lithium toxicity? What can precipitate it?
- Serum lithium >1.5mmol/L - >2mmol/L = life-threatening - Dehydration, renal failure, diuretics, anti-HTNs + NSAIDs
235
LITHIUM TOXICITY What is... i) acute ii) chronic iii) acute-on-chronic lithium toxicity?
i) Acute ingestion in patient not chronically on lithium ii) Patients on long-term lithium without acute OD iii) Ingestion of excess lithium in patients on chronic lithium
236
LITHIUM TOXICITY What is the clinical presentation of lithium toxicity?
- Ataxia, dysarthria, confusion (drunk) - COARSE tremor, blurred vision, hyperreflexia - N+V, diarrhoea - Myoclonus, seizures + coma if severe
237
LITHIUM TOXICITY What are some complications of lithium toxicity?
- Arrhythmias (VT) - Acute renal failure - Syndrome of irreversible lithium-effectuated neurotoxicity (SILENT) after cessation of lithium >2m = truncal ataxia, ataxic gait, scanning speech, incoordination
238
LITHIUM TOXICITY What is the management of lithium toxicity?
- ABCDE approach as emergency - Stop + check lithium levels, serum creatinine, U+Es - IV fluids (bolus + 1.5–2x maintenance - ?Whole bowel irrigation with polyethene glycol for severe, acute ingestion - Haemodialysis
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LITHIUM TOXICITY When would you do haemodialysis in lithium toxicity?
- Serum [Li] >5mmol/L OR >4 + renal dysfunction OR severe toxicity (seizures, coma, life-threatening arrhythmias)
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ACUTE DYSTONIA What is an acute dystonic reaction?
- Sustained painful muscle contraction in ≥1 muscle groups
241
ACUTE DYSTONIA What is the clinical presentation of acute dystonic reaction?
- Rapid onset after dose given or changed - Spasm of muscles of tongue, face, neck + back - Oculogyric crisis (prolonged involuntary upward deviation of eyes) - Torticollis (twisted neck) - Tongue protrusion
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ACUTE DYSTONIA What is the management of acute dystonia?
- ABCDE approach as emergency - Anticholinergic – IM procyclidine - Stop antipsychotic (switch to atypical as less EPSEs)
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NMS What is the pathophysiology of neuroleptic malignant syndrome (NMS)?
- Dopamine antagonism often due to typical antipsychotic OD or acute withdrawal of Parkinson's meds
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NMS what are the risk factors?
- recent initiation or dose increase of neuroleptic medications (within 2 weeks) - use of high potency 1st gen anti-psychotics (haloperidol, fluphenazine) - male sex - previous episode of NMS - parkinsonism
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NMS How quickly does NMS present?
- Onset within 2w of drug or dose change (onset + progression slow) - May last 7–10d after PO or 21d after depot
246
NMS What is the clinical presentation?
develops over days to weeks SYMPTOMS - altered mental state - muscle discomfort - confusion - agitation - sweating SIGNS - fever >38 degrees - reduced GCS - generalised muscle rigidity (lead-pipe rigidity) - tachycardia - hyporeflexia
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NMS What are the complications of NMS?
- Resp failure, CV collapse - Rhabdomyolysis - DIC
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NMS What are some investigations for NMS?
- FBC (leukocytosis) - Low serum iron - U+Es, Ca2+, phosphate - Urinary myoglobin (raised) - Serum creatinine phosphokinase (CPK) may be raised - CK = raised
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NMS What is the management of NMS?
- ABCDE approach 1ST LINE - Stop antipsychotic (wait >2w before restarting, consider atypical) - Give L-dopa if dopamine withdrawal in Parkinson's - supportive care (IV rehydration) 2ND LINE - IV dantrolene or lorazepam to reduce rigidity 1st line (amantadine second) - Bromocriptine prophylaxis
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NMS What is the supportive management for NMS?
- Oxygen, cooling blankets, antipyretics, ice-water enema for pyrexia - IV access to correct volume depletion + reduce risk of rhabdomyolysis with fluids (cooled)
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NMS How is risk of rhabdomyolysis reduced?
- Vigorous hydration - Alkalinisation with IV sodium bicarbonate (target urine pH of 6)
252
SEROTONIN SYNDROME What is serotonin syndrome?
- Disorder caused by excess serotonin in brain
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SEROTONIN SYNDROME What are some causes of serotonin syndrome?
- Antidepressants = SSRIs (inhibit reuptake), SNRIs, St. John's wart, MAOI (decreased metabolism) - Drugs = ecstasy, amphetamines, LSD, anti-emetics
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SEROTONIN SYNDROME What is the clinical presentation of serotonin syndrome?
develops within 24hrs SYMPTOMS - shivering - headache - diarrhoea - agitation - pressured speech - hypervigilance SIGNS - hypertension - tachycardia - mydriasis - myoclonus - hyperreflexia - hyperthermia - muscle rigidity
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SEROTONIN SYNDROME What are some investigations for serotonin syndrome?
- FBC, U+Es, biochemistry (Ca2+, Mg2+, phosphate), CK, drug toxicology scren - ECG monitoring for prolonged QRS or QTc interval
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SEROTONIN SYNDROME What is the management of serotonin syndrome?
- ABCDE 1ST LINE - discontinuation of serotonergic agent - supportive care (IV fluids + treatment of hyperthermia) - benzodiazepines (DIAZEPAM) 2ND LINE - cyproheptadine (if symptoms persist)
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SEROTONIN SYNDROME What is the management of serotonergic drug OD?
- ?Gastric lavage ± activated charcoal
258
LEARNING DISABILITIES What is a learning disability?
- Condition of arrested or incomplete development of mind, characterised by impairment of skills that contribute to overall intelligence (language, cognition, social) which has manifested during developmental period
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LEARNING DISABILITIES How is a learning disability different to learning difficulties?
- Learning difficulties (dyslexia) are difficulties in acquiring knowledge + skills to the normal level expected of those of the same age, especially due to a mental disability or cognitive disorder
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LEARNING DISABILITIES What is the triad in learning disabilities?
- Low intellectual performance (IQ < 70) - Onset during birth or early childhood - Wide range of functional impairment
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LEARNING DISABILITIES What is the epidemiology of learning disabilities?
- M>F, biggest risk factor is FHx
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LEARNING DISABILITIES What are some causes of learning disabilities?
- Genetic = Down's, Fragile X, Prader-Willi, neurofibromatosis - Antenatal = TORCH - Perinatal = asphyxia, intraventricular haemorrhage - Postnatal = meningitis, kernicterus - Environmental = malnutrition, smoking or alcohol in pregnancy
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LEARNING DISABILITIES What physical disorders may be present in those with learning disabilities?
- Motor disabilities (ataxia, spasticity) - Epilepsy - Impaired hearing/vision - Incontinence
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LEARNING DISABILITIES How is mild learning disability characterised by... i) IQ? ii) mental age? iii) mobility? iv) speech? v) academia? vi) self-care?
i) 50–69 ii) 9–12 iii) Mobile iv) Mostly adequate v) Difficulties reading + writing vi) Most independent
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LEARNING DISABILITIES How is moderate learning disability characterised by... i) IQ? ii) mental age? iii) mobility? iv) speech? v) academia? vi) self-care?
i) 35–49 ii) 6–9 iii) Mobile iv) Simple-no speech, may sign, reasonable comprehension v) Limited, some learn to read, write + count vi) Lifelong supervision, may need prompting + support
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LEARNING DISABILITIES How is severe learning disability characterised by... i) IQ? ii) mental age? iii) mobility? iv) speech? v) academia? vi) self-care?
i) 20–34 ii) 3–6 iii) Marked impairment iv) Simple-no speech, may sign, reasonable comprehension v) Limited, some learn to read, write + count vi) Lifelong supervision, may need prompting + support
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LEARNING DISABILITIES How is profound learning disability characterised by... i) IQ? ii) mental age? iii) mobility? iv) speech? v) academia? vi) self-care?
i) <20 ii) <3 iii) Severe impairment iv) Basic non-verbal comms, understands basic commands v) None vi) Complete dependency
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AUTISM SPECTRUM What is autism?
- Pervasive development disorder which manifests before age 3
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AUTISM SPECTRUM What are some risk factors for autism?
- M>F - Obstetric complications - Perinatal infection (rubella) - Genetic disorders (Fragile X, Down's)
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AUTISM SPECTRUM What are the 3 areas of impaired functioning that need to be present in autism?
- Social interaction - Communication (speech + language) - Behaviour (imposition of routine with ritualistic or repetitive behaviour)
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AUTISM SPECTRUM Give some examples of impaired social interaction
- Failure to notice + respond to social cues + others' emotional states - Difficulty establishing friendships - Lack of eye contact - Delay in smiling
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AUTISM SPECTRUM Give some examples of impaired communication
- Expressive speech + comprehension usually delayed or minimal - Concrete thinking (lack imagination) - Absence of gestures - Later speech consists of monologues, endless questions, echolalia
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AUTISM SPECTRUM Give some examples of impaired behaviours
- Inability to adapt to new environments (distress) - Tendency to have rigid routine with resistance to change - Greater interest in objects, numbers + patterns than people - Stereotypical repetitive movements which may be self-stimulating movements to comfort themselves (rocking, hand-flapping)
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AUTISM SPECTRUM What is the management of autism?
- No cure so MDT for best environment to support child + parent - CAMHS, paediatrician, SALT, dieticians, social workers, specially trained educators, special school environments - Picture based timetables - Charities for support (national autistic society)
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TIC DISORDERS What are tics?
- Repetitive, involuntary, purposeless movements + sounds
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TIC DISORDERS What is Tourette's syndrome?
- Development of tics that are persistent for >1y - More severe expression of the spectrum of tic disorder
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ADHD What is attention deficit hyperactivity disorder (ADHD)?
behavioural disorder characterised by difficulty concentrating. characterised by inattention and hyperactivity
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ADHD What are some risk factors for ADHD?
- boys and men - history of neurodevelopmental disorder (autism + other learning difficulties) - family history of ADHD or other mental health disorder - premature birth - epilepsy
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ADHD What is the epidemiology of ADHD?
- M>F - Dx between 6–12y (must be ≥6y but show Sx before 12y)
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ADHD What is the triad of symptoms in ADHD?
- Inattention - Impulsivity - Hyperactivity
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ADHD How does inattention present?
- lack of attention to detail - difficult holding attention in tasks - easily distracted - difficulty following instructions - difficulty listening to direct speech - difficulty organising tasks and activities - avoidant of tasks that require mental effort - frequently lose things necessary for tasks (e.g. pen, phone, keys) - forgetful in daily activities
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ADHD How does impulsivity present?
- Blurts answer before questions completed - Difficulty awaiting turn - Interrupts others - Teenagers have impulsive behaviours (car accidents, pregnancy)
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ADHD How does hyperactivity present?
- Constantly fidgeting - Constant "on the go" or "driven by a motor" - Excessive talking
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ADHD what are the investigations?
- clinical assessment - behavioural rating scales - school reports + observations - Features consistent across ≥2 settings (home, school) - Diagnosed ≥6y when Sx present continuously for ≥6m - Information from teachers, school reports, family etc used
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ADHD What is the management of ADHD?
Conservative initially (watch + wait) – - Family education on ADHD + parenting advice - Establish normal balanced diet, exercise can improve Sx - Food diary to identify any triggers + eliminate with dietician - 1st line = Methylphenidate (“Ritalin“) -2nd line = Lisdexamfetamine - 3rd line = Atomoxetine
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ADHD What is the management for severe ADHD?
- CNS stimulants like methylphenidate (increase monoamine pathway activity, not addictive) - S/E = appetite suppression, insomnia, psychosis, important to monitor growth, baseline ECG (cardiotoxic) - Atomoxetine (SE = liver dysfunction, suicidality) - (Lis)dexamfetamine
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SOMATISATION DISORDER What is somatisation disorder?
- Multiple, atypical + inconsistent presentations with MUS, affecting multiple organ systems. - Symptoms present ≥2y, F>>M
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SOMATISATION DISORDER What is the clinical presentation of somatisation disorder?
- Non-specific + atypical Sx (usually derm, GI) - Discrepancy between subjective + objective findings (S = Sx) - Sx often in one system, may move to another once Dx possibilities exhausted - Often results in multiple needless investigations + operations (pt refuses to accept -ve results)
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SOMATISATION DISORDER What is the management of somatisation disorder?
- Rule out all organic illnesses - Communicate Dx but acknowledge Sx severity - Reassure patient of continuing care - May benefit from CBT, group therapy or psychotherapy
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COUNSELLING What is counselling?
- Relieving distress via dialogue between 2 people - Therapist listens + helps patient find own solutions
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PSYCHOEDUCATION What is psychoeducation?
- Briefing patients about their illness so they understand it better - Problem solving training so they know how to deal with it better - Communication training so they can express their emotions better - Self-assertiveness training, relatives included
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CBT What is the role of cognitive behavioural therapy (CBT)?
- Identify + challenge negative thoughts + modify abnormal core beliefs - Based on idea disorder not caused by life events but way patient views these events > better emotional regulation
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DBT What is dialectical behavioural therapy (DBT)?
- Helps to change unhelpful ways of thinking (anger) + behaving (self-harm) like CBT but also focuses on accepting who you are at same time (accept + change
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DBT What are the two components to DBT?
- Individual therapy = therapist validates pt's responses, reinforces adaptive behaviours + facilitates analysis of maladaptive behaviours + their triggers - Group therapy = teaching on mindfulness, interpersonal effectiveness skills (problem solving, communication), emotional modulation skills
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PSYCHOANALYTICAL PSYCHOTHERAPY What is psychoanalytical psychotherapy?
- Childhood experiences, past conflicts + relationships influence individual's current situation - Once inner struggles brought to light, behaviour + feelings improve
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GROUP PSYCHOTHERAPY What is group psychotherapy? Give some examples
- Individuals brought together under therapist's guidance with goals of reducing distress + Sx, increasing coping or improving relationships - Support groups, activity groups (art, music), self-help groups (AA)
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FAMILY THERAPY What is family therapy?
- Enables those in close relationships to better understand, support each other better, explore each other's thoughts + build on family strengths together
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INTERPERSONAL THERAPY What is interpersonal therapy? What is it used in?
- Identify + address problems in their relationships with idea that poor relationships can leave you depressed + depression in turn can make relationships worse - Depression (severe or not responded to other therapies)
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BEHAVIOURAL ACTIVATION What is behavioural activation therapy? What is it used for?
- Aim to give patients motivation to make simple, practical steps towards enjoying life again - Also teaches problem-solving skills - Depression
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GENDER DYSPHORIA What is gender dysphoria?
- Mismatch between biological sex + gender identity of an individual causing distress
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GENDER DYSPHORIA Define... i) transsexual ii) trans woman iii) trans man
i) Person who emotionally + psychologically feels that they belong to opposite sex ii) Assigned male sex 46XY at birth who later identifies as a woman iii) Assigned female sex 46XX who later identifies as a man
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GENDER DYSPHORIA What act is relevant to gender dysphoria?
- Gender recognition act 2004 - Allows transsexual people to legally change their gender - Have to demonstrate Dx of gender dysphoria + have lived as gender role for ≥2y
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GENDER DYSPHORIA What is the clinical presentation of gender dysphoria?
- Low self-esteem, self-neglect, social isolation - Depression, anxiety + suicidality - Only comfortable when in preferred gender role - Strong desire to hide physical signs + dislike of genitals of biological sex
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GENDER DYSPHORIA What is the management of gender dysphoria in... i) <18? ii) >18?
i) Referral to gender identity development service (GIDS) with MDT (CAMHS, clinical psychologist, social worker, family therapist) ii) Referral to gender dysphoria clinic (GP or self-referral)
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GENDER DYSPHORIA What surgical procedures may be offered?
- TM = mastectomy, hysterectomy, nipple repositioning, phalloplasty or penile implant, scrotoplasty + testicular implants - TW = orchidectomy, penectomy, vaginoplasty, vulvoplasty or clitoroplasty
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GENDER DYSPHORIA What biological treatment can be used in <16y?
- Very few young people who meet strict criteria may have gonadotropin-releasing hormone analogues (hormone blockers) as reach puberty
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GENDER DYSPHORIA What biological treatment can be used >16?
- Cross-sex/gender-affirming hormones if on hormone blockers for ≥12m – Oestrogen for breasts + feminine features – Testosterone for deep voice + masculine features (body hair)
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GENDER DYSPHORIA What psychological treatment can be given to... i) <18y? ii) >18y?
i) Family therapy, individual child psychotherapy, parental support/counselling ii) Counselling, SALT to help sound like gender identity
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GENDER DYSPHORIA What social management is there for gender dysphoria?
- Quit smoking (may increase risks of side effects from treatments) - Lose weight if overweight to reduce risks from cross-sex hormones) - Social transitioning incl. changing name by deed poll
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GENDER DYSPHORIA What are some risks of the hormone therapy?
- Oestrogen = clots, gallstones, high triglycerides - Testosterone = polycythaemia, acne, dyslipidaemia - Both = elevated LFTs, infertility, weight gain
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SCHIZOAFFECTIVE What are the two types of schizoaffective disorder?
Manic type or depressive type
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SCHIZOAFFECTIVE How does it differ to schizophrenia?
Psychotic Sx tend to wax + wane, unlike in schizophrenia
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SELF-HARM What are some causes of self-harm?
Bullying, bereavement, homophobia, low self-esteem
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SELF-HARM Why do people self harm?
Feel in control, reduces feelings of tension or distress, if they feel guilty can be a punishment
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SELF-HARM What are some methods of self-harm?
- Self-poisoning (paracetamol), cutting, head banging
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SELF-HARM What are some risk factors for self-harm?
Female Social deprivation, Single or divorced, LGBTQ+, mental illness
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SUICIDE What is suicide?
- Act of intentionally ending your life
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SUICIDE What are some methods?
Overdose, violent means (jumping from height, into traffic, hanging, cutting)
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BIPOLAR DISORDER What are some risk factors?
FHx of depression or bipolar, genetics, traumatic life event (abuse), drugs + other meds (antidepressants, BDZs, steroids) sleep deprivation
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SCHIZOPHRENIA What area of the brain is most affected?
Temporal lobe
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SCHIZOPHRENIA What is the epidemiology of schizophrenia?
- 1% lifetime risk, M=F, mortality 25y before gen pop. - Affects 1/100, 2 incidence peaks – men earlier (18–25), women (25–35)
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SCHIZOPHRENIA What are the features of hebephrenic schizophrenia?
Dx in adolescents with mood changes, unpredictable behaviour, shallow affect + fragmentary hallucinations, poor outlook as -ve Sx may develop rapidly
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SCHIZOPHRENIA What are the features of simple schizophrenia?
Pts never really experienced +ve Sx, mostly -ve
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AUTISM SPECTRUM What is associated with autism?
- Learning difficulties
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AUTISM SPECTRUM What is Asperger's syndrome?
- ASD without cognitive impairment + fewer problems with language
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TIC DISORDERS What might cause them?
- Stress, gestational + perinatal insults, PANDAS
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TIC DISORDERS How does Tourette's syndrome present?
- Multiple motor tics + at least 1 phonic tic (coprolalia)
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ACUTE DYSTONIA What is the life-threatening complication?
Laryngeal dystonia > airway compromised
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ACUTE DYSTONIA What may it be caused by?
- ?Imbalance of dopamine + cholinergic transmission where D2 receptors become so blocked that excess output of cholinergics
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ANOREXIA NERVOSA What are the consequences of refeeding syndrome?
Can lead to cardiac arrhythmias, convulsions, cardiac failure, coma + death
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ANOREXIA NERVOSA What is the outcome of anorexia nervosa?
1/3 recover, 1/3 relapse + remit, 1/3 chronic lifelong
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OCD What is a potential cause of OCD?
Neurochemical dysregulation of 5-HT system
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PHENOMENOLOGY What is a mental disorder?
Any disorder or disability of the mind, excluding substance abuse
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PHENOMENOLOGY Define psychosis
Severe mental disturbance characterised by a loss of contact with external reality (schizophrenia)
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PHENOMENOLOGY Define neurosis
Relatively mild mental illness in which there is no loss of connection with reality (depression, anxiety)
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PHENOMENOLOGY Define phenomenology
The study of signs + symptoms describing abnormal states of mind
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PHENOMENOLOGY Define illusion
The false perception of a real external stimulus
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PHENOMENOLOGY Define hallucination
An internal perception occurring without a corresponding external stimulus. The person experiences it as they would a real perception.
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PHENOMENOLOGY In terms of hallucinations, what are the main senses?
Auditory, visual, olfactory, gustatory, tactile
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PHENOMENOLOGY What is Charles-Bonnet Syndrome? What conditions may it be seen in?
- Complex visual hallucinations in a patient with partial/severe blindness (macular degeneration, diabetic retinopathy). - Pts understand that the hallucinations are not real + so often have insight
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PHENOMENOLOGY Define pseudo-hallucination
A perception in the absence of an external stimulus, experienced in one's subjective inner space of the mind rather than external sensory objects – often have insight
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PHENOMENOLOGY Define delusion
A fixed, false, unshakable belief which is out of keeping with the patient's educational, cultural + social norms. It's held with extraordinary conviction + certainty (even despite contradictory evidence)
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PHENOMENOLOGY In terms of delusions, what are persecutory?
the idea that someone/something is trying to inflict harm on them (being followed, poisoned, drugged, spied)
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PHENOMENOLOGY In terms of delusions, what are... i) poverty? ii) reference? iii) inadequacy? iv) religious?
i) pt strongly believes they are financially incapacitated ii) false belief that insignificant remarks/objects in one's environment have personal meaning/significance (newspaper has hidden text related to them) iii) false belief of inability to accomplish tasks + meet expectations iv) false belief related to religious themes/subject matter.
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PHENOMENOLOGY | What are the 3 delusional misidentification syndromes?
- Capgras = idea someone has been replaced by an imposter. - Fregoli = idea various people are the same person - Intermetamorphosis = one significant relative is replaced by another (father is son).
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PHENOMENOLOGY Define delusional perception and give an example
A primary delusion of two components – where a normal perception is subject to delusional interpretation E.g. – traffic light changed red so that means I am the son of God
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PHENOMENOLOGY Define thought alienation
Sx of psychosis in which patients feel that their own thoughts are in some way no longer in their control
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PHENOMENOLOGY Define concrete thinking
Loss of ability to understand abstract concepts + metaphorical ideas leading to a strictly literal form of speech
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PHENOMENOLOGY Define thought disorder and formal thought disorder
TD = disorganised thinking as evidenced by disorganised speech/beliefs FTD = pts expressive language (form) indicates that the links between consecutive thoughts aren't meaningful (disorganised speech evident from disorganised thinking)
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PHENOMENOLOGY In terms of thought disorders, what is flight of ideas?
Abrupt leaps between topics as a result of thoughts presenting more rapidly than can be articulated. Each thought = more associations. ?Discernible links between successive ideas. Presents as pressure of speech.
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PHENOMENOLOGY In terms of thought disorders, what is thought block?
sudden + unintentional break in chain of thought, may be explained as due to thought withdrawal
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PHENOMENOLOGY Define confabulation + state what conditions you would find this in
Giving a false account to fill in a gap in memory. | Korsakoff's psychosis + dementia
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PHENOMENOLOGY Define passivity phenomena + somatic passivity
- Delusion that one is a passive recipient of actions from an external agency against their will - The same but sensations are controlled by an external agency
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PHENOMENOLOGY Define psychomotor retardation + state what conditions you would find this in
- Slowing of thoughts + movements with decreased spontaneous movement, often due to subjective sense of actions being laborious - Parkinson's, depression
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PHENOMENOLOGY Define incongruity of affect
Emotional responses that differs markedly from the expected emotion for the situation/subject like laughing whilst discussing trauma
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PHENOMENOLOGY Define blunting of affect
A limited range of normal emotional responsiveness
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PHENOMENOLOGY Define flattening of affect
Diminution of the normal range of emotions
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PHENOMENOLOGY Define depersonalisation + derealisation
- Where a person doesn't believe themselves to be real - Where a person doesn't believe the world/people around them to be real
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PHENOMENOLOGY Define obsession
Recurrent thoughts/feelings/images/impulses which are intrusive + persistent despite efforts to resist. They are recognised as the person's own thoughts (insight preserved)
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PHENOMENOLOGY Define compulsion
Repetitive, purposeful behaviour performed in response to an obsession despite the recognition of its senselessness + anxiety if not performed
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PHENOMENOLOGY Define thought echo
Experience of an auditory hallucination in which the content is the individual's current thoughts spoken aloud as if next to them
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PHENOMENOLOGY Define catatonia/stupor
Abnormality of movement + behaviour arising from a disturbed mental state, typically severe depression or schizophrenia
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PHENOMENOLOGY Define anhedonia
Inability to feel pleasure in normally pleasurable activities
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PHENOMENOLOGY Define belle indifference
A surprising lack of concern for, or denial of, apparently severe functional disability (not specific to psych)
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PHENOMENOLOGY Define dissociation
When a person feels disconnected from themselves or their surroundings (including emotions)
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PHENOMENOLOGY Define conversion
Development of features suggestive of physical illness but which are attributed to psych illness or emotional disturbance rather than organic pathology
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PHENOMENOLOGY Define sterotypy
Repetitive + bizarre act which is not goal-directed. Action may have delusional significance to the pt
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PHENOMENOLOGY Define mannerism
Abnormal + occasionally bizarre performance of voluntary, goal-directed activity
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PHENOMENOLOGY Define projection + give an example
What is emotionally unacceptable in the self is unconsciously rejected + projected to others (e.g. mother projects anxiety on children claiming they're anxious)
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PHENOMENOLOGY Define over-valued idea
A false or exaggerated belief held with conviction but not with delusional intensity. This idea although perhaps reasonable, dominates their life + causes distress
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PHENOMENOLOGY What are somatic hallucinations?
within the person
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PHENOMENOLOGY What are hypnogogic/hypnopompic hallucinations?
hypnogogic = when going to sleep hypnopompic = when waking up
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PHENOMENOLOGY What are autoscopic hallucinations?
seeing oneself
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PHENOMENOLOGY What are reflex hallucinations?
production of a hallucination in one sensory modality by a stimulus in a different modality
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PHENOMENOLOGY What are extracampine hallucinations?
hallucinations which are experienced outside the normal sensory field (seeing something behind them)
376
PHENOMENOLOGY In terms of delusions, what are grandiose?
idea that the person themselves are powerful/crucially important beyond truth
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PHENOMENOLOGY In terms of delusions, what are nihilistic?
theme involves intense feelings of emptiness, sense of everything being unreal
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PHENOMENOLOGY In terms of delusions, what are guilt?
ungrounded feeling of remorse or guilt for situations, can be due to a minor error or unrelated to them (may feel responsible for world disasters)
379
PHENOMENOLOGY What are the 3 components of thought alienation?
thought insertion, withdrawal and broadcast
380
PHENOMENOLOGY What is thought insertion?
Insertion = delusional belief thoughts placed into pts head from external
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PHENOMENOLOGY What is thought broadcast?
Broadcast = delusional belief thoughts are accessible directly to others without expressing them
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PHENOMENOLOGY What is thought withdrawal?
Withdrawal = delusional belief thoughts removed from head from external
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PHENOMENOLOGY In terms of thought disorders, what is circumstantiality?
irrelevant wandering in conversation (going around the point).
384
PHENOMENOLOGY Define loosening of associations
This is thought disorder denoting a lack of connection between ideas. Links between ideas may be illogical or the speech may wander between trains of thought. It is also known as knight's move thinking
385
PHENOMENOLOGY define pressure of speech
a tendency to speak rapidly, motivated by an urgency that may not be apparent to the listener
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PHENOMENOLOGY define akathisia
an inability to keep still, restlessness
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PHENOMENOLOGY define perseveration
When someone gets stuck on a topic or an idea There may be repetition of words or phrases
388
ANTI-PSYCHOTICS What are the two types of anti-psychotics?
- Typical/1st generation - Atypical/2nd generation
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ANTI-PSYCHOTICS What is the mechanism of action of typical (1st generation) anti-psychotics?
- D2 receptor antagonist - Reduced release of dopamine from dopaminergic neurones + so reduced electrical activity in dopaminergic pathways
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ANTI-PSYCHOTICS What pathway do typical (1st generation) anti-psychotics work on to have anti-psychotic effect?
Mesolimbic pathway (reduces +ve Sx)
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ANTI-PSYCHOTICS What is the mechanism of action of atypical (2nd generation) anti-psychotics?
- Antagonists at dopamine D2 receptors but more selective in dopamine blockade + so block serotonin 5-HT2a
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ANTI-PSYCHOTICS What is the most crucial adverse effect of clozapine?
- Severe life-threatening agranulocytosis
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ANTI-PSYCHOTICS What are the 5 broad categories of SEs caused by anti-psychotics?
- Extra-pyramidal side effects (EPSEs) - Hyperprolactinaemia - Metabolic - Anticholinergic - Neurological
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ANTI-PSYCHOTICS What are the extra-pyramidal side effects (EPSEs) of anti-psychotics?
- Acute dystonic reaction - Parkinsonism - Akathisia - Tardive dyskinesia
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ANTI-PSYCHOTICS How does Parkinsonism present?
- Bradykinesia, rigid, resting pill-rolling tremor + postural instability
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ANTI-PSYCHOTICS How does akathisia present?
- Motor restlessness, typically lower legs (can't sit still)
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ANTI-PSYCHOTICS How does tardive dyskinesia present?
- Purposeless involuntary movements (chewing, lip smacking, blinking, tongue protrusion)
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ANTI-PSYCHOTICS What are the SEs from hyperprolactinaemia?
- Sexual dysfunction (+ anti-adrenergic) - Osteoporosis risk - Amenorrhoea - Galactorrhoea, gynaecomastia + hypogonadism in men
399
ANTI-PSYCHOTICS What are the metabolic SEs?
- Weight gain (esp. olanzapine) - Hyperlipidaemia, risk of stroke + VTE in elderly - T2DM risk + metabolic syndrome
400
ANTI-PSYCHOTICS What are the anticholinergic SEs?
Can't see, pee, spit, shit – - Blurred vision - Urinary retention - Dry mouth - Constipation + tachycardia
401
ANTI-PSYCHOTICS What are the neurological SEs?
- Seizures - Postural hypotension (anti-adrenergic) - Sedation - Headaches
402
ANTI-PSYCHOTICS What baseline investigations are done for people starting on anti-psychotics?
- FBC, U+Es, LFTs, lipids, BMI, fasting glucose, prolactin, BP, ECG (QTc prolongation) + smoking status (can reduce effects by enhancing metabolism so issues if suddenly stop)
403
ANTI-PSYCHOTICS What regular investigations are done for people on anti-psychotics?
- Lipids + BMI at 3m - Fasting glucose + prolactin at 6m - Frequent BP during dose titration - FBC, U+Es, LFTs, lipids, BMI, fasting glucose, prolactin + CV risk yearly
404
ANTI-PSYCHOTICS What specific monitoring is required for clozapine?
- FBC at baseline + weekly for 18w, fortnightly until 1y + monthly after
405
ANTI-DEPRESSANTS What monitoring is needed when starting someone on an anti-depressant?
- 2 weekly to ensure dose working + patient stable, may take up to 6w to start working, - weekly if <30y as increased suicide risk
406
ANTI-DEPRESSANTS How should anti-depressants be stopped? Why?
- Gradual dose reduction over 4w - Sudden cessation can cause severe withdrawal effects (mostly GI) – pain, diarrhoea, vomiting, restlessness, sweating + mood change
407
ANTI-DEPRESSANTS how would you switch from one SSRI to another?
- in general, gradually withdraw first SSRI, then start the alternative SSRI - exception is switching from fluoxetine to another SSRI - stop fluoxetine + start new SSRI at low dose 4-7 days later
408
ANTI-DEPRESSANTS What is the mechanism of action of SSRIs? Give some examples
- Prevents reuptake + subsequent degradation of serotonin from synaptic cleft by inhibiting its reuptake transporter on the post-synaptic membrane - Prolonged serotonin in synaptic cleft = prolonged neuronal activity - Citalopram, sertraline, fluoxetine
409
ANTI-DEPRESSANTS What are the side effects of SSRIs?
- GI Sx most common (N+V, hyponatraemia, abdo pain, bowel issues, increased bleed risk) - Sedation + sexual impotence - Citalopram + QTc prolongation (dose-dependent)
410
ANTI-DEPRESSANTS What are some cautions for SSRIs?
- Suicidal thoughts may increase initially, esp. younger patients - May precipitate manic phase in bipolar - 1st trimester risk of CHD, 3rd trimester risk of persistent pulmonary HTN
411
ANTI-DEPRESSANTS What are some interactions for SSRIs?
- NSAIDs + aspirin = increased risk of bleeding, co-prescribe PPI - Can lower seizure threshold - Do not start until 2w after stopping MAOI + vice-versa as increased risk of serotonin syndrome
412
ANTI-DEPRESSANTS What is the mechanism of action of SNRIs?
- Prevents reuptake + subsequent degradation of serotonin AND noradrenaline from synaptic cleft by inhibiting reuptake transporters on post-synaptic membrane
413
ANTI-DEPRESSANTS What are some side effects of SNRIs?
- GI (N+V, constipation), central/peripheral effects (SIADH, rhabdomyolysis)
414
ANTI-DEPRESSANTS What is the mechanism of action of monoamine oxidase inhibitors (MAOI)?
- Inhibits monoamine oxidase enzyme which reduces breakdown of adrenaline, noradrenaline + serotonin so increases level
415
ANTI-DEPRESSANTS What are some side effects from MAOIs?
- Sexual dysfunction, weight gain + postural hypotension
416
ANTI-DEPRESSANTS What are some cautions with MAOIs?
- Increased risk of serotonin syndrome if used with other serotonergic drugs - Hypertensive crisis with ingestion of foods containing tyramine (aged cheeses, smoked/cured meats, pickled herring, Bovril, Marmite)
417
ANTI-DEPRESSANTS What is the mechanism of action of tricyclic antidepressants (TCAs)?
- Prevents reuptake + subsequent degradation of serotonin + noradrenaline from synaptic cleft by inhibiting reuptake transporters on post-synaptic neuronal membrane
418
ANTI-DEPRESSANTS What are the side effects of TCAs?
- Anticholinergic (can't see, pee, spit, shit)
419
ANTI-DEPRESSANTS What cautions are there for TCAs?
- Caution in CVD, avoid following MI - Cardiotoxic in overdose so caution in suicidal patients (QTc prolongation)
420
ANTI-DEPRESSANTS In terms of TCA overdose... i) mild-moderate Sx? ii) severe Sx?
i) Dilated pupils, dry mouth, urinary retention, increased tendon reflexes + extensor plantars ii) Fits, coma, cardiac arrhythmias > arrest
421
ANTI-DEPRESSANTS What is the mechanism of action of mirtazapine?
- Blocks alpha-2 adrenergic receptors > increased release of neurotransmitters
422
MOOD STABILISERS What are some examples of mood stabilisers?
Lithium (first line) AEDs such as valproate, carbamazepine, lamotrigine
423
MOOD STABILISERS What are the side effects of lithium?
LITHIUM – - Leukocytosis - Insipidus (diabetes, nephrogenic) - Tremors (fine if SE, coarse if toxicity) - Hydration (easily dehydrates, renally cleared) - Increased GI motility (N+V, diarrhoea) - Underactive thyroid - Mums beware (Ebstein's anomaly) Can cause weight gain + derm (acne, psoriasis) long-term too
424
MOOD STABILISERS What drugs does lithium interact with?
- NSAIDs, ACEi, ARBs + diuretics may increase lithium levels - Diuretics = dehydration, NSAIDs = renal damage
425
MOOD STABILISERS What baseline measurements are taken for lithium?
- FBC, U+Es, eGFR, TFTs, BMI + ECG
426
MOOD STABILISERS What regular monitoring is done for lithium?
- Weekly serum lithium after initiation + dose changes until stable then every 3m for a year, then every 6m (sample taken 12h after dose) - 6m = TFTs, U+Es, eGFR - Annual = BMI
427
MOOD STABILISERS What might carbamazepine and lamotrigine interfere with?
- Contraceptive pill
428
HYPNOTICS What is the mechanism of action of hypnotics?
- GABA agonists on alpha2-subunit of GABA(A)-BDZ receptor/Cl- channel complex
429
ANTI-PSYCHOTICS What are the issues for typical anti-psychotics?
Not selective so can bind to other dopaminergic pathways causing generalised dopamine receptor blockade
430
ANTI-PSYCHOTICS What pathway do typical anti-psychotics work on to cause side effects?
Nigrostriatal (Parkinsonism), tuberoinfundibular (prolactin)
431
ANTI-PSYCHOTICS What is the benefit of atypical anti-psychotics?
More useful in treating -ve Sx of schizophrenia + less likely to cause EPSEs
432
ANTI-PSYCHOTICS What anti-psychotic has a reduced SE profile and why?
Aripiprazole as it is a partial dopamine agonist
433
ANTI-PSYCHOTICS What is the most common adverse effect of clozapine? What other adverse effects may it have?
- Constipation (big issue in elderly) - Reduced seizure threshold, hypersalivation (Rx hyoscine hydrobromide)
434
ANTI-PSYCHOTICS How is parkinsonism managed?
Reduce dose or switch to atypical anti-psychotic
435
ANTI-PSYCHOTICS Why is akathisia dangerous?
It is a massive risk factor for suicide in young men with schizophrenia
436
ANTI-PSYCHOTICS How is akathisia managed?
Reduce dose, introduce beta-blocker (propranolol)
437
ANTI-PSYCHOTICS When does tardive dyskinesia present?
After months-years of Tx
438
ANTI-PSYCHOTICS How is tardive dyskinesia managed?
Prevention crucial, switch to atypical anti-psychotic, tetrabenazine used if mod–severe but unlikely to completely resolve
439
ANTI-DEPRESSANTS When can an anti-depressant be stopped?
- Carried on 6m after Sx resolved even if patient feels better
440
ANTI-DEPRESSANTS What are some interactions of SNRIs?
- NSAIDs warfarin (increased risk of bleeding), lower seizure threshold
441
ANTI-PSYCHOTICS Give an example of a typical (1st generation) anti-psychotic.
haloperidol, flupentixol zuclopenthixol (decanoate = depot) chlorpromazine
442
ANTI-PSYCHOTICS Give examples of atypical (2nd generation) psychotics.
olanzapine, risperidone (depot), clozapine, aripiprazole (depot), quetiapine
443
ANTI-DEPRESSANTS Give some examples of SNRIs?
Venlafaxine, duloxetine
444
ANTI-DEPRESSANTS Give some examples of monoamine oxidase inhibitors (MAOI)? Give some examples.
- Selegiline is selective MAO-B inhibitor which also increases dopamine - Isocarboxazid, phenelzine
445
ANTI-DEPRESSANTS Give some examples of tricyclic antidepressants (TCAs)?
Amitriptyline, dosulepin, imipramine
446
ANTI-DEPRESSANTS In terms of TCA overdose what are the ECG signs?
Sinus tachy, wide QRS, prolonged QT interval
447
ANTI-DEPRESSANTS What is the management of a TCA overdose?
Sodium bicarbonate
448
ANTI-DEPRESSANTS What are some side effects of mirtazapine?
Increased appetite + weight gain + sedation are big ones, also increased triglyceride levels
449
MOOD STABILISERS What is the mechanism of action of mood stabilisers?
Lithium inhibits cAMP production which inhibits monoamines
450
MOOD STABILISERS What is important to note about mood stabilisers?
Narrow therapeutic range 0.4–1.0mmol/L
451
HYPNOTICS Give some examples
Zopiclone, zolpidem, BDZs used for hypnotic effect (lorazepam, temazepam)
452
HYPNOTICS What are the adverse effects?
Same as BDZs - Amnesia, ataxia (esp elderly = falls risk), confusion, drowsiness, dizziness next day (hangover effect), tolerance - Monitor for resp depression (caution in resp disease)
453
BDZs What is the mechanism of action of anxiolytics/benzodiazepines (BDZs)?
- Enhance effect of inhibitory GABA by increasing frequency of Cl- channels + flow of Cl- ions causing hyperpolarisation of membrane + so prevention of further excitation
454
BDZs Give some examples of BDZs?
- Diazepam (longer duration), lorazepam + temazepam (shorter duration), clonazepam, chlordiazepoxide
455
BDZs What are some adverse effects of BDZs?
- Amnesia, ataxia (esp elderly = falls risk), confusion, drowsiness, dizziness next day (hangover effect), tolerance - Monitor for resp depression (caution in resp disease)
456
BDZs How would you manage an overdose? What is the risk of using this?
IV flumazenil (danger of inducing status epilepticus or death though)
457
SUBSTANCE ABUSE Why is something addictive?
Related to dopamine + mesolimbic reward system a motivational circuit
458
SUBSTANCE ABUSE What are the physical effects of dependent drug use?
- Acute = injecting complications, SEs, OD, poor pregnancy outcomes - Chronic = BBV transmission, chronic illnesses
459
SUBSTANCE ABUSE What are the... i) psychological ii) social effects of dependent drug use?
i) MH issues, fearing withdrawal, craving, guilt, pre-occupation with finding next fix ii) Effects on relationships, criminality + imprisonment, social exclusion, poverty (no money for food)
460
SUBSTANCE ABUSE What is dependence?
- The inability to control the intake of a substance to which one is addicted to
461
SUBSTANCE ABUSE List 8 features of dependence
- Withdrawal - Cravings - Continued use despite harm - Tolerance - Primacy/salience - Loss of control - Narrowed repertoire - Rapid reinstatement
462
SUBSTANCE ABUSE What is withdrawal? Give an example
- Physiological withdrawal state when substance stopped with Sx + substance use to prevent - Early morning drinking
463
SUBSTANCE ABUSE What are cravings?
- Very strong desire for the substance
464
SUBSTANCE ABUSE What is continued use despite harm? Give an example
- Despite clear problems caused by substance, person cannot stop - Injecting heroin despite abscess formation
465
SUBSTANCE ABUSE What is tolerance? Give an example
- Larger doses required to gain the same effect as previously (NB: individuals often show no signs of being on a drug at dose ordinary people would) - Opiate-dependent people may inject enough heroin to kill a non-tolerant person
466
SUBSTANCE ABUSE What is primacy/salience? Give an example
- Obtaining + using substance becomes so important other interests are neglected - Not eating to save money for drugs
467
SUBSTANCE ABUSE What is loss of control? Give an example
- Difficulties controlling starting, stopping or amounts used - Becomes hard to say no
468
SUBSTANCE ABUSE What is narrowed repertoire? Give an example
- Less variation in types of substances used - Dependent drinker will drink same amount of same drink in same way (usually cheapest)
469
SUBSTANCE ABUSE What is rapid reinstatement? Give an example
- When a user relapses after period of abstinence, risk of returning to previous dependent pattern quicker - Someone who used to smoke 10/d may quickly return to this after 1 fag
470
SUBSTANCE ABUSE What are some primary care interventions for drug users?
- Health checks + BBV screening - Contraception, smear + sexual health advice - General immunisation status + hep A/B - Information on local drug services (needle exchange)
471
SUBSTANCE ABUSE How can harm be reduced in drug users?
- Not injecting or safe injecting (don't share, new one each time) - Not mixing resp depressants or using drugs alone - Reduce amount taken after intervals tolerance is lost
472
ALCOHOL DEPENDENCE What is alcohol abuse?
- Regular or binge consumption of alcohol which is sufficient to cause physical, neurological, psychiatric or social damage
473
ALCOHOL DEPENDENCE What is the recommended weekly units for men and women?
14 units/week
474
ALCOHOL DEPENDENCE What are the components to alcohol abuse?
- Psychological dependence = feelings of loss of control, cravings, pre-occupation - Physiological dependence = physical withdrawal Sx - +ve reinforcement = drinking to feel euphoric - -ve reinforcement = drinking to avoid withdrawal Sx
475
ALCOHOL DEPENDENCE What areas of the brain can alcohol affect?
- Amygdala + nucleus accumbens - Cerebral cortex - Pre-frontal cortex - Cerebellum - Hypothalamus + pituitary - Medulla
476
ALCOHOL DEPENDENCE How does alcohol affect... i) amygdala + nucleus accumbens? ii) cerebral cortex? iii) pre-frontal cortex? iv) cerebellum? v) hypothalamus + pituitary? vi) medulla?
i) Euphoria, pleasure + reward centre ii) Slows thinking + speech iii) Slow behavioural inhibition centres (confident + relaxed) iv) Slows movement + impairs coordination v) Alters mood + hormones (libido increases) vi) Decreases breathing, consciousness + body temp
477
ALCOHOL DEPENDENCE How does alcohol affect the activity of neurotransmitters in the brain?
- Ethanol > ADH > acetaldehyde > ALDH > acetate > CO2 + H2O - Ethanol binds to GABA + makes inhibitor/depressant effect stronger - Glutamate antagonism which decreases excitatory neurotransmission - Activates opioid receptors to release endorphins - Release dopamine + serotonin
478
ALCOHOL DEPENDENCE What are some causes/risk factors for alcohol dependence?
- Genetics – more likely if FHx, M>F, less likely if acetaldehyde dehydrogenase deficiency - Occupation – army, Drs - Culture/beliefs/background – high in Scottish, Irish, lower in Muslims + Jews - Cost of alcohol - Early use of substances - Social reinforcement - Chronic illnesses - Traumatic life events
479
ALCOHOL DEPENDENCE What are the acute effects of alcohol intoxication? When is it classed as alcohol dependence?
- Euphoria, impaired judgement, reduced anxiety, ataxia, vomiting - ≥3 features of dependence
480
ALCOHOL DEPENDENCE What are the 3 stages of alcohol withdrawal?
- 6–12h = tremors, sweating, tachycardia, anxiety, irritability + aggression - 36h = seizures - 48–72h = delirium tremens
481
ALCOHOL DEPENDENCE What are some chronic complications of alcohol dependence?
- Cardiac = dilated cardiomyopathy, arrhythmias - Liver etc – fibrosis, cirrhosis, oesophageal varices, pancreatitis - Wernicke's + Korsakoff's
482
ALCOHOL DEPENDENCE What are some common causes of death in alcohol dependence?
- Accidents + violence - Malignancies (head + neck, pancreatic, stomach, colon, hepatic, breast + gynae) - CVA, IHD
483
ALCOHOL DEPENDENCE What are some blood markers for alcohol consumption?
- Red blood cell mean corpuscular volume (MCV) raised - Gamma glutamyl transpeptidase (GGT) raised - Carbohydrate deficient transferrin (CDT) raised
484
ALCOHOL DEPENDENCE What are some clinical tools for assessing alcohol dependence or withdrawal?
- CAGE - AUDIT - Clinical Institute Withdrawal Assessment
485
ALCOHOL DEPENDENCE What are the CAGE questions?
- Have you ever felt you need to CUT down on your drinking? - Have people ANNOYED you by criticising your drink? - Have you ever felt GUILTY about your drinking? - EYE-opener – ever felt you need drink first thing in morning to steady your nerves?
486
ALCOHOL DEPENDENCE What are the AUDIT questions?
- How often do you have a drink containing alcohol? - How many units of alcohol do you drink on a typical day? - How often did you have >6 units on a single occasion in the past year?
487
ALCOHOL DEPENDENCE What is blood alcohol content? How is it affected? What is the drink drive limit?
- mg ethanol/100ml blood - Affected by amount of ethanol consumed, person's blood volume (males have increased), if eaten, any meds - Illegal to drive with BAC ≥0.08%
488
ALCOHOL DEPENDENCE What are public health measurements to help prevent alcohol abuse?
- Increasing tax on alcohol + restricting advertisement on alcohol - Drinkaware + know your limits campaign - Keeping alcohol out of site (behind counter + having to ask for it) - School alcohol education to reduce long-term alcohol use + binge drinking
489
ALCOHOL DEPENDENCE What are the indications for an inpatient detoxification?
- Withdrawal seizures or delirium tremens in past - Significant mental/physical illness, including suicidality - Lack of stable home environment
490
ALCOHOL DEPENDENCE What is the regime for acute detoxification?
- Chlordiazepoxide 1st line (2nd = diazepam, lorazepam is preferred for pts with liver cirrhosis) for withdrawal Sx + preventing seizures - Thiamine (PO or IV) - Rehydrate with fluids (often IV), correct electrolyte disturbance - Reducing regime (slowly reduce doses over days)
491
ALCOHOL DEPENDENCE What factors make detoxification more likely to work?
- Younger users with less time addicted + lower level of drug use
492
ALCOHOL DEPENDENCE What are the 3 biological treatments used in alcohol dependence?
- Naltrexone - Acamprosate - Disulfiram
493
ALCOHOL DEPENDENCE What is the mechanism of action of naltrexone?
- Opioid receptor antagonist - Blocks euphoric effects of alcohol - Helps people stick to detox programme + avoid relapse
494
ALCOHOL DEPENDENCE What is the mechanism of action of acamprosate?
- NMDA antagonist acts on GABA to reduce cravings + risk of relapse
495
ALCOHOL DEPENDENCE What is the mechanism of action of disulfiram? What affects does it have?
- Inhibits acetaldehyde dehydrogenase > build-up of acetaldehyde - Produces hangover-like Sx when alcohol is drunk = deterrent (flushing, headaches, anxiety, nausea, reduced BP)
496
ALCOHOL DEPENDENCE What are some psychological treatments for alcohol dependence?
- Motivational intervention - Aversion therapy - CBT, prevention measures (relapse prevention strategies)
497
ALCOHOL DEPENDENCE What is motivational intervention?
- Discuss potential harm caused, reasons for changing behaviour, cover obstacles to change, strategies to combat obstacles > motivation
498
ALCOHOL DEPENDENCE What is aversion therapy?
- Designed to put the patient off the undesirable habit by causing them to associate it with an unpleasant effect
499
ALCOHOL DEPENDENCE What is the social management of alcohol dependence?
- Housing, economical + employment issues - Alcoholics anonymous - Developing social routines that are not reliant on alcohol
500
OPIATES/OPIOIDS What are opiates?
- Derived from opium poppy, synthetic compounds with similar properties are called opioids with heroin most commonly abused
501
OPIATES/OPIOIDS How do opioids work?
- Bind to m-receptor > endogenous endorphins causing cortical inhibitor effects (analgesia) almost immediately - Addictive as high reward for minimal effort
502
OPIATES/OPIOIDS What routes can opioids be taken via? How long does it take for withdrawal symptoms to develop? What are some examples?
- Smoking, PO, snorted, parenterally (IM/IV) - 6h post-dose - Morphine, diamorphine (heroin), codeine, methadone
503
OPIATES/OPIOIDS With opioids, what is the... i) psych effect? ii) physical effect?
i) Euphoria, relaxation, drowsiness, analgesia ii) Resp depression (esp. OD), pinpoint pupils, bradycardia, constipation
504
OPIATES/OPIOIDS What are some complications with injecting heroin?
- Abscesses, cellulitis, infective endocarditis, BBV (hep B/C, HIV), VTE
505
OPIATES/OPIOIDS What is the management of opioid overdose?
- 400mg IV naloxone - M-receptor inverse agonist > blockade (almost immediate)
506
OPIATES/OPIOIDS What are some maintenance therapies for opioids?
- Methadone (full opioid agonist) or buprenorphine (partial agonist/antagonist) - Start low + titrate up
507
OPIATES/OPIOIDS What are the pros of methadone?
- Reduces mortality, drug-related morbidity, crime, spread of BBV
508
OPIATES/OPIOIDS How does maintenance therapies help?
- Don't get high but reduces cravings - Less dangerous than heroin + safe in pregnancy (risk of miscarriage if stop in pregnancy)
509
OPIATES/OPIOIDS What drug can be used to prevent relapses?
- Naltrexone - Opiate antagonist which prevents lapse > relapse
510
OPIATES/OPIOIDS What is the first line detox management in opioids? How long does detox last?
- Motivational intervention - Alternative therapies = exercise, art therapy, counselling - 4w = inpatient, 12w = community
511
SEDATIVES What are some types of sedatives? What is a 'date-rape' drug? What routes can it be taken?
- BDZs, barbiturates (increased duration of Cl- channels) often taken for their anxiolytic effects - Rohypnol > intoxicant, aphrodisiac + anterograde amnesia - PO + IV
512
SEDATIVES What are the withdrawal effects of sedatives?
Sweating, myalgia, tremors, risk of seizures
513
STIMULANTS What are some examples?
Cocaine, ecstasy (MDMA), amphetamines (speed)
514
STIMULANTS What different routes of taking these drugs?
- Cocaine inhaled or IV - MDMA + amphetamines PO - Crack cocaine releases all dopamine straight away when smoked
515
STIMULANTS What are the withdrawal effects of stimulants?
Psychomotor agitation, dysphoric mood, insomnia bizarre/unpleasant dreams
516
STIMULANTS What are some other adverse effects of cocaine?
- Arrhythmias, MI + damage to nasal septum if used chronically
517
STIMULANTS what is the management of cocaine toxicity?
- 1st line = benzodiazepines - chest pain = benzodiazepines + GTN - MI = PCI - HTN = benzodiazepines + sodium nitroprusside
518
CANNABINOIDS Why is cannabis addictive? What can heavy use lead to?
- Addictive as causes release of dopamine, anxiolytic - Anxiety + depression, use in youth > schizophrenia
519
CANNABINOIDS What are the... i) psych ii) physical effects of cannabinoids?
i) Euphoria + disinhibition, hallucinations, paranoid, agitation, time passes slowly ii) Increased appetite, dry mouth, tachycardia
520
HALLUCINOGENS What are some psych + physical effects of hallucinogens?
- Hallucinations, illusions, depersonalisation + derealisation, paranoia, impulsivity, anxiety, magic mushrooms > euphoria as serotonin release - Tachycardia, palpitations, sweating, blurred vision
521
VOLATILE SOLVENTS Give some examples of solvents.
- Aerosols, paint, glue, petrol (inhaled)
522
BDZs What are they suitable for?
Short-term Tx (<4w), sedation + anxiolytic
523
BDZs What drugs can BDZs interact with?
- Anti-hypertensives as enhanced hypotensive effect
524
SUBSTANCE ABUSE What is an addiction?
- Compulsive substance taking behaviour with physiological withdrawal state
525
SUBSTANCE ABUSE What is an addictive behaviour?
Behaviour which is both rewarding + reinforcing
526
ALCOHOL DEPENDENCE How do you calculate number of units in a drink?
- % ABV x volume (L)
527
ALCOHOL DEPENDENCE What is 1 unit of alcohol?
10ml or 8g
528
ANTI-PSYCHOTICS what is the general mechanism of action for anti-psychotics?
psychosis is thought to be caused be an excess of dopamine therefore anti-psychotics aim to reduce dopamine by blocking receptors
529
ANTI-PSYCHOTICS What is the most crucial adverse effect of clozapine?
- Severe life-threatening agranulocytosis
530
OPIATES/OPIOIDS What are some complications from opioids?
- Resp depression, constipation, N+V, coma, OD + death
531
OPIATES/OPIOIDS With opioids, what are the symptoms of withdrawal
"Goose flesh" (piloerection), raised HR/BP, fever, pupil dilatation, abdo cramps, insomnia, agitation (everything runs > D+V, lacrimation, rhinorrhoea, diaphoresis)
532
SEDATIVES What are the... i) psych ii) physical effects of sedatives?
i) Euphoria + disinhibition, hallucinations, paranoid, agitation, time passes slowly ii) Unsteady gait, dysarthria, hypotension, nystagmus iii) Sweating, myalgia, tremors, risk of seizures
533
ANTI-PSYCHOTICS What happens if a patient does not take their clozapine for 48 hours?
If not taken for 48hr needs retitrating
534
ANTIPSYCHOTICS what is the effect of smoking on clozapine?
- when smoking a higher level of clozapine may be required to get therapeutic dose - if stopping smoking a lower dose of clozapine may be required
535
STIMULANTS What is the action of stimulants?
- Potentiate mood enhancing neurotransmission (dopamine, serotonin, noradrenaline) by blocking their uptake + increase cortical excitability
536
STIMULANTS What are the... i) psych ii) physical effects of stimulants?
i) Euphoria, increased alertness + endurance, grandiosity, hallucinations, aggression, impulsivity ii) Tachycardia, HTN, N+V, pupil dilation, CP + convulsions
537
CANNABINOIDS What are the withdrawal effects of cannabinoids?
Anxiety, irritable, tremor, conjunctival injection
538
HALLUCINOGENS Give some examples of hallucinogens
- LSD, magic mushrooms (PO)
539
VOLATILE SOLVENTS What are some psych + physical effects of solvents?
- Apathy, lethargy, impaired judgement, psychomotor retardation - Decreased consciousness, unsteady gait, diplopia
540
VOLATILE SOLVENTS Are the effects of solvents dangerous?
Very – laryngospasm due to cold temp, brain damage, hypoxia
541
ACUTE STRESS DISORDER what is it?
an acute stress reaction that occurs in the first 4 weeks after a person has been exposed to a traumatic event
542
ACUTE STRESS DISORDER what are the clinical features?
- intrusive thoughts (flashbacks, nightmares) - dissociation (being in a daze, time slowing) - negative mood - avoidance - arousal (hypervigilance, sleep disturbance)
543
ACUTE STRESS DISORDER what is the management?
- trauma focused CBT - benzodiazepines (short term and for acute symptoms)